Sarah K. Calabrese

Genital Appearance Dissatisfaction: Implications for Women's Genital Image Self-Consciousness, Sexual Esteem, Sexual Satisfaction, and Sexual Risk

Findings regarding the link between body image and sexuality have been equivocal, possibly because of the insensitivity of many body image measures to potential variability across sensory aspects of the body (e.g., appearance versus odor), individual body parts (e.g., genitalia versus thighs), and social settings (e.g., public versus intimate). The current study refined existing methods of evaluating womens body image in the context of sexuality by focusing upon two highly specified dimensions: satisfaction with the visual appearance of the genitalia and self-consciousness about the genitalia during a sexual encounter. Genital appearance dissatisfaction, genital image self-consciousness, and multiple facets of sexuality were examined among a sample of 217 undergraduate women using an online survey. Path analysis revealed that greater dissatisfaction with genital appearance was associated with higher genital image self-consciousness during physical intimacy, which, in turn, was associated with lower sexual esteem, sexual satisfaction, and motivation to avoid risky sexual behavior. These findings underscore the detrimental impact of negative genital perceptions on young womens sexual well-being, which is of particular concern given their vulnerability at this stage of sexual development as well as the high rates of sexually transmitted infections within this age group. Interventions that enhance satisfaction with the natural appearance of their genitalia could facilitate the development of a healthy sexual self-concept and provide long-term benefits in terms of sexual safety and satisfaction.

Evulvalution: The Portrayal of Women's External Genitalia and Physique across Time and the Current Barbie Doll Ideals

Media images of the female body commonly represent reigning appearance ideals of the era in which they are published. To date, limited documentation of the genital appearance ideals in mainstream media exists. Analysis 1 sought to describe genital appearance ideals (i.e., mons pubis and labia majora visibility, labia minora size and color, and pubic hair style) and general physique ideals (i.e., hip, waist, and bust size, height, weight, and body mass index [BMI]) across time based on 647 Playboy Magazine centerfolds published between 1953 and 2007. Analysis 2 focused exclusively on the genital appearance ideals embodied by models in 185 Playboy photographs published between 2007 and 2008. Taken together, results suggest the perpetuation of a “Barbie Doll” ideal characterized by a low BMI, narrow hips, a prominent bust, and hairless, undefined genitalia resembling those of a prepubescent female.

The pleasure principle: the effect of perceived pleasure loss associated with condoms on unprotected anal intercourse among immigrant Latino men who have sex with men.

Sexual pleasure has been identified as an important consideration in decision-making surrounding condom use. We examined the impact of perceived pleasure loss associated with condom use on recent history of insertive and receptive unprotected anal intercourse (UAI) among Latino men who have sex with men (MSM) living in the United States. A total of 482 Dominican, Colombian, and Brazilian immigrant MSM were surveyed regarding sexual attitudes and practices via computer-assisted self-interviewing technology with audio enhancement (ACASI). Participants rated the pleasure they derived from protected and unprotected anal intercourse in each position (insertive and receptive) and also reported their HIV status, relationship status, and recent sexual history. Men who had engaged in both positions, with and without condoms (n=268), perceived a greater pleasure loss associated with condoms during anal intercourse in the insertive versus receptive position. Logistic regression analyses controlling for HIV status, relationship status, and age revealed that men who perceived greater pleasure loss from condoms were more likely to have engaged in UAI over the past 3 months (n[insertive]=297; n[receptive]=284). Findings indicate that the pleasure loss associated with condoms may be a key deterrent for their use in either sex position among Latino MSM. Therefore, pleasure needs to be prioritized in the development of condoms and other sexual safety measures as well as in the promotion of their use.

A comparison of adherence assessment methods utilized in the United States: perspectives of researchers, HIV-infected children, and their caregivers.

This study sought to elucidate methodological issues in adherence research by comparing multiple methods of assessing adherence to antiretroviral medication. From 2003 to 2004, 24 youths with vertically infected HIV disease (mean age = 14.0 years; range, 8-18) and their caregivers participated in a 6-month study. These children were all on highly active antiretroviral therapy (HAART) and were relatively healthy (mean CD4 absolute count = 711.8 +/- 604.5). Adherence was assessed with the Medication Event Monitoring System (MEMS), pill counts, and interviews. Patients and caregivers completed the Perceptions of Adherence Study Participation (PASP) questionnaire. MEMS provided the most detailed adherence information, and good reliability was indicated by significant correlations with medical markers. Pill counts provided similar adherence rates, while patients and caregivers reported nearly perfect adherence in interviews. Problems were experienced with each method: MEMS were expensive, had cap malfunctions, and lack a consistent guiding principle for data interpretation. With pill counts, families forgot to bring all medication bottles to clinic, and interviews were compromised by social desirability and difficulty reaching families by telephone. Most patients and caregivers believed study participation improved the childs adherence, although PASP ratings were unrelated to adherence at the study endpoint. While MEMS may be most reliable, pill counts offer comparable data and are less costly, while interviews seemed least accurate in this study. Most participants reported positive perceptions of their research experience. A consensus among researchers is needed for defining and measuring adherence, and specific recommendations are offered for achieving this goal.

Exploring Discrimination and Mental Health Disparities Faced By Black Sexual Minority Women Using a Minority Stress Framework.

Black sexual minority women are triply marginalized due to their race, gender, and sexual orientation. We compared three dimensions of discrimination—frequency (regularity of occurrences), scope (number of types of discriminatory acts experienced), and number of bases (number of social statuses to which discrimination was attributed)—and self-reported mental health (depressive symptoms, psychological well-being, and social well-being) between 64 Black sexual minority women and each of two groups sharing two of three marginalized statuses: (a) 67 White sexual minority women and (b) 67 Black sexual minority men. Black sexual minority women reported greater discrimination frequency, scope, and number of bases and poorer psychological and social well-being than White sexual minority women and more discrimination bases, a higher level of depressive symptoms, and poorer social well-being than Black sexual minority men. We then tested and contrasted dimensions of discrimination as mediators between social status (race or gender) and mental health outcomes. Discrimination frequency and scope mediated the association between race and mental health, with a stronger effect via frequency among sexual minority women. Number of discrimination bases mediated the association between gender and mental health among Black sexual minorities. Future research and clinical practice would benefit from considering Black sexual minority women’s mental health in a multidimensional minority stress context.

Resilience, stress, and life quality in older adults living with HIV/AIDS

Objectives: This study tested the mediating effect of resilience on the relationship between life stress and health-related quality of life (HRQoL) in older people, 50 years of age and older, living with HIV/AIDS (OPLWHA). Method: Data from 299 OPLWHA were analyzed using structural equation modeling (SEM) to define a novel resilience construct (represented by coping self-efficacy, active coping, hope/optimism, and social support) and to assess mediating effects of resilience on the association between life stress and HRQoL (physical, emotional, and functional/global well-being). Results: SEM analyses showed satisfactory model fit for both resilience and mediational models, with resilience mediating the associations between life stress and physical, emotional, and functional/global well-being. Conclusion: Resilience may reduce the negative influence of life stress on physical, emotional, and functional/global well-being in OPLWHA. Interventions that build personal capacity, coping skills, and social support may contribute to better management of HIV/AIDS and increase HRQoL.

An Event-Level Comparison of Risk-Related Sexual Practices Between Black and Other-Race Men Who Have Sex with Men: Condoms, Semen, Lubricant, and Rectal Douching

Black men who have sex with men (MSM) living in the U.S. are disproportionately affected by HIV/AIDS. An online survey of sexual behavior was completed by Black, White, Hispanic/Latino, Asian/Pacific Islander, and other-race MSM (n=11,766) ages 18-87 years. Complete condom use, semen exposure, pre-coital rectal douching (enema use), and lubricant use at last male-partnered sexual event were compared by race, controlling for relevant sociodemographic variables and stratifying by sexual position (receptive, insertive, or both). Across sexual positions, 55-62% of Black MSM reported condom use, 5-8% reported semen exposure, 18-53% reported douching, and 33-43% reported lubricant use. Reported behavioral profiles were not significantly different from other races, except that Black MSM reported greater condom use than White MSM in the insertive position. Although findings argue against disproportionate rates of risk behavior accounting for racial disparities in HIV prevalence, they nonetheless highlight a need for continued behavioral intervention.

The Antiretroviral Regimen Complexity Index. A novel method of quantifying regimen complexity.

Background:Individuals with HIV disease often must adhere to complex medication regimens. To date, regimen complexity has not been examined in the literature using standardized procedures incorporating all important elements of antiretroviral (ARV) regimens. Objective:This article presents a novel method of quantifying regimen complexity using objective criteria addressing the factors that may complicate adherence to ARV regimens. Methods:Part 1 of this article describes the development of the Antiretroviral Regimen Complexity (ARC) Index scoring system. Based on input from pediatric and adult patients, caregivers of pediatric patients, and health care professionals, this comprehensive system includes the number of medications, dosing schedules, administration methods, special instructions, and required preparations associated with ARV regimens. Weights are applied for each of these factors to produce an overall score representing the regimens level of complexity. Part 2 of this article presents reliability and validity data for the system. Results:The ARC Index demonstrates excellent test-retest and interrater reliability as well as strong construct and discriminant validity. An on-line version of this system minimizes computation errors. Conclusions:Although modifications may be necessary for patients requiring nonstandard dosing instructions, preliminary evidence supports the utility of this measure as a reliable and valid indicator of the complexity of antiretroviral treatment regimens.

A Qualitative Study of Medical Mistrust, Perceived Discrimination, and Risk Behavior Disclosure to Clinicians by U.S. Male Sex Workers and Other Men Who Have Sex with Men: Implications for Biomedical HIV Prevention

Access to biomedical HIV prevention technologies such as pre-exposure prophylaxis (PrEP) requires individuals to disclose risk behavior to clinicians, but experiences of discrimination and medical mistrust may limit disclosure among male sex workers and other MSM. We explored experiences of perceived discrimination, medical mistrust, and behavior disclosure among male sex workers compared to other men who have sex with men (MSM). We conducted 56 interviews with MSM and compared findings about medical mistrust, discrimination, and disclosure for 31 men who engaged in sex work vs. 25 men who did not. MSM who engaged in sex work reported more medical mistrust and healthcare discrimination due to issues beyond MSM behavior/identity (e.g., homelessness, substance use, poverty). MSM who did not report sex work described disclosing sex with men to clinicians more often. Both subgroups reported low PrEP awareness, but willingness to disclose behavior to obtain PrEP. Medical mistrust and perceived discrimination create barriers for sexual behavior disclosure to clinicians, potentially impeding access to PrEP and other forms of biomedical HIV prevention. These barriers may be higher among male sex workers compared to other MSM, given overlapping stigmas including sex work, substance use, homelessness, and poverty. An intersectionality framework for understanding multiple stigmas can help to identify how these dynamics may limit access to biomedical HIV prevention among male sex workers, as well as suggesting strategies for addressing stigmas to improve the delivery of PrEP and other HIV prevention approaches in this population.

Putting PrEP into Practice: Lessons Learned from Early-Adopting U.S. Providers’ Firsthand Experiences Providing HIV Pre-Exposure Prophylaxis and Associated Care

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers’ adoption of PrEP into clinical practice. This qualitative study explored PrEP providers’ firsthand experiences relative to six commonly-cited barriers to prescription—financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)—as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014–2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.