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Repetitive negative thinking linked to dementia risk

“Looking after your mental health is important, and it should be a major public health priority, as it’s not only important for people’s health and well-being in the short term, but it could also impact your eventual risk of dementia.”

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Persistently engaging in negative thinking patterns may raise the risk of Alzheimer’s disease, finds a new UCL-led study.

In the study of people aged over 55, published in Alzheimer’s & Dementia, researchers found ‘repetitive negative thinking’ (RNT) is linked to subsequent cognitive decline as well as the deposition of harmful brain proteins linked to Alzheimer’s.

The researchers say RNT should now be further investigated as a potential risk factor for dementia, and psychological tools, such as mindfulness or meditation, should be studied to see if these could reduce dementia risk.

Lead author Dr Natalie Marchant (UCL Psychiatry) said: “Depression and anxiety in mid-life and old age are already known to be risk factors for dementia. Here, we found that certain thinking patterns implicated in depression and anxiety could be an underlying reason why people with those disorders are more likely to develop dementia.

“Taken alongside other studies, which link depression and anxiety with dementia risk, we expect that chronic negative thinking patterns over a long period of time could increase the risk of dementia. We do not think the evidence suggests that short-term setbacks would increase one’s risk of dementia.

“We hope that our findings could be used to develop strategies to lower people’s risk of dementia by helping them to reduce their negative thinking patterns.”

For the Alzheimer’s Society-supported study, the research team from UCL, INSERM and McGill University studied 292 people over the age of 55 who were part of the PREVENT-AD cohort study, and a further 68 people from the IMAP+ cohort.

Over a period of two years, the study participants responded to questions about how they typically think about negative experiences, focusing on RNT patterns like rumination about the past and worry about the future. The participants also completed measures of depression and anxiety symptoms.

Their cognitive function was assessed, measuring memory, attention, spatial cognition, and language. Some (113) of the participants also underwent PET brain scans, measuring deposits of tau and amyloid, two proteins which cause the most common type of dementia, Alzheimer’s disease, when they build up in the brain.

The researchers found that people who exhibited higher RNT patterns experienced more cognitive decline over a four-year period, and declines in memory (which is among the earlier signs of Alzheimer’s disease), and they were more likely to have amyloid and tau deposits in their brain.

Depression and anxiety were associated with subsequent cognitive decline but not with either amyloid or tau deposition, suggesting that RNT could be the main reason why depression and anxiety contribute to Alzheimer’s disease risk.

“We propose that repetitive negative thinking may be a new risk factor for dementia as it could contribute to dementia in a unique way,” said Dr Marchant.

The researchers suggest that RNT may contribute to Alzheimer’s risk via its impact on indicators of stress such as high blood pressure, as other studies have found that physiological stress can contribute to amyloid and tau deposition.

Co-author Dr Gael Chételat (INSERM and Université de Caen-Normandie) commented: “Our thoughts can have a biological impact on our physical health, which might be positive or negative. Mental training practices such as meditation might help promoting positive- while down-regulating negative-associated mental schemes.

“Looking after your mental health is important, and it should be a major public health priority, as it’s not only important for people’s health and well-being in the short term, but it could also impact your eventual risk of dementia.”

The researchers hope to find out if reducing RNT, possibly through mindfulness training or targeted talk therapy, could in turn reduce the risk of dementia. Dr Marchant and Dr Chételat and other European researchers are currently working on a large project to see if interventions such as meditation may help reduce dementia risk by supporting mental health in old age.

Fiona Carragher, Director of Research and Influencing at Alzheimer’s Society, said: “Understanding the factors that can increase the risk of dementia is vital in helping us improve our knowledge of this devastating condition and, where possible, developing prevention strategies. The link shown between repeated negative thinking patterns and both cognitive decline and harmful deposits is interesting although we need further investigation to understand this better. Most of the people in the study were already identified as being at higher risk of Alzheimer’s disease, so we would need to see if these results are echoed within the general population and if repeated negative thinking increases the risk of Alzheimer’s disease itself.

“During these unstable times, we are hearing from people every day on our Alzheimer’s Society Dementia Connect line who are feeling scared, confused, or struggling with their mental health. So it’s important to point out that this isn’t saying a short-term period of negative thinking will cause Alzheimer’s disease. Mental health could be a vital cog in the prevention and treatment of dementia; more research will tell us to what extent.”

This is also an issue among members of the LGBTQIA community. In 2019, for instance, a study found that more than 14% of sexual and gender minorities (SGM) reported subjective cognitive decline, significantly higher (p<0.0001) than the 10% rate among cisgender heterosexual participants.

In 2018, meanwhile, SAGE CEO Michael Adams noted: “While the LGBT community faces similar health concerns as the general public, LGBT people who receive a dementia diagnosis and LGBT caregivers face uniquely challenging circumstances. This brief shines a light on these challenges, so we can begin taking steps to address them and improve the care and support LGBT people receive.”

Health & Wellness

Gender harassment and institutional betrayal in high school take toll on mental health

97% of women and 96% of men from a pool of 535 undergraduate college students had endured at least one instance of gender harassment during high school. Experiences of gender harassment, especially for those who encountered it repeatedly, were associated with clinically relevant levels of trauma-related symptoms in college.

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High school students who endure gender harassment in schools that don’t respond well enter college and adulthood with potential mental health challenges, according to a University of Oregon study.

The study, published last month in PLOS ONE, found that 97% of women and 96% of men from a pool of 535 undergraduate college students had endured at least one instance of gender harassment during high school.

Experiences of gender harassment, especially for those who encountered it repeatedly, were associated with clinically relevant levels of trauma-related symptoms in college.

“We found that the more gender harassment and institutional betrayal teens encounter in high school, the more mental, physical and emotional challenges they experience in college,” said lead author Monika N. Lind, a UO psychology doctoral student. “Our findings suggest that gender harassment and institutional betrayal may hurt young people, and educators and researchers should pay more attention to these issues.”

The study, the three-member UO team noted, served to launch academic research into the responses of high schools to gender harassment, beyond media reports of institutional betrayal by schools since the #MeToo movement began.

Gender harassment, a type of sexual harassment, is characterized by sexist remarks, sexually crude or offensive behavior and the enforcement of traditional gender roles.

Institutional betrayal, a label coined previously by the study’s co-author UO psychologist Jennifer Freyd, is the failure of an institution, such as a school, to protect people who depend on it. A high school mishandling a case of gender harassment reported by a student is an example of institutional betrayal.

“The more gender harassment and institutional betrayal teens encounter in high school, the more mental, physical and emotional challenges they experience in college,” said lead author Monika N. Lind.

Participants included 363 females, 168 males, three non-binary and one who did not report gender; they were initially not aware of the study’s focus.

They completed a 20-item gender harassment questionnaire about their high school experiences and a 12-item questionnaire about their schools’ actions or inactions. Trauma symptoms were assessed with a 40-item checklist that explores common posttraumatic symptoms such as headaches, memory problems, anxiety attacks, nightmares, sexual problems and insomnia.

Photo by Sharon McCutcheon from Unsplash.com

An analysis that considered gender, race, age, gender harassment, institutional betrayal, and the interaction of gender harassment and institutional betrayal significantly predicted trauma-related symptoms, but, Lind said, a subtle surprise emerged.

“We expected to find an interaction effect showing that the relationship between gender harassment and trauma-related symptoms depends on institutional betrayal, such that people who experience high gender harassment have different levels of symptoms depending on how much institutional betrayal they experience,” she said. “Instead we found that gender harassment and institutional betrayal are independently related to trauma-related symptoms.”

That issue, Lind said, needs to be further explored. It’s possible, she said, that the pool of students wasn’t large enough or that the measures used were not robust enough. Another factor may be that the study focused more on institutional betrayal than impacts of institutional courage.

“This is like measuring mood and only letting respondents report negative to neutral mood – you’re missing a bunch of variability that might be captured if you extended the scale to go from negative to positive,” she said. “Expanding the scale to capture institutional courage might increase the likelihood of identifying a meaningful interaction.”

Experiences of gender harassment, especially for those who encountered it repeatedly, were associated with clinically relevant levels of trauma-related symptoms in college.

How schools might respond to the issues identified in the study should begin with listening to students, Lind said. Asking about problems and listening to responses is an example of institutional courage. Interventions that do not do so often fail.

“Schools should engage in self-study, including interviews, focus groups and anonymous surveys of students, and they should take students’ reports and suggestions seriously,” Lind said. “When you’re trying to intervene in adolescence, you’ll do better if you demonstrate respect for teens’ autonomy and social status.”

Researchers have not focused on such issues in high schools, where students are emerging into early adulthood from the physical, neurological and psychological changes occurring in adolescence, said Freyd, a pioneer in academic research on issues of sexual harassment, institutional betrayal and institutional courage.

“Until now, all of the education-focused institutional betrayal research has considered the experiences of undergraduate and graduate-level college students, as well as those of faculty members,” she said. “There also has been work on these issues in the military and workplaces, but we don’t know a lot about gender harassment or institutional betrayal in adolescence.”

UO doctoral student Alexis A. Adams-Clark, a member of Freyd’s lab, was the study’s third co-author.

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Health & Wellness

There are two sides to every story

In the Philippines, one in five people suffers from mental health problems. Between 17% and 20% of Filipino adults experience psychiatric disorders, while 10% to 15% of Filipino children suffer from mental health problems. But addressing mental health is not yet among the priorities in the country.

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It all happened one busy Monday, in between unfinished deadlines and piling up of workload. The conversation suddenly ended, and it left him dumfounded. He kept looking for answers why it happened. He questioned himself; reviewed all his replies. Everything seemed okay.

His name is Andy. He considers himself as an introvert. There may be times when he can be talkative, but “that is different; I am not face-to-face with the person.”

Sometimes, people call him a “player,” claiming that he just wants to hook them into his “game”.

What not everyone knows is that whenever he starts to be close to someone, he (un)consciously builds walls around him, preventing anyone to get through particularly when he feels there is an attempt to make a deeper connection.

Andy said his intentions are always good. But most of the time, “I am read wrong and taken negatively.”

And every time that kind of thing happens, it just contributes to the sound he has been hearing in his head.

Running away

Sometimes it takes on the form of fear… fear of the current situation or the unknown. There are times when it invades his dreams, waking him up in the middle of the night with either a bad headache or heavy breathing. It is usually mistaken as stress.

A glass of warm milk or chilled rosé, a dosage of paracetamol or Valium, counting backwards from 100 while listening to calming music – any of these usually help, but only temporary.

“I found out a few years back that I am dealing with emotional and psychological trauma. I never knew I had one,” Andy said.

A type of mental health condition, trauma is a response to a stressful event. This is usually triggered by a terrifying situation, either experiencing or witnessing it firsthand.

Edgewood Health Network Canada listed down some of the most common symptoms of psychological trauma, i.e.:

  1. Disruptive recollections of the trauma, including flashbacks
  2. Emotional and physical reactions in response to reminders
  3. Negative beliefs about oneself or others
  4. Inability to feel close to others
  5. Being easily startled
  6. Dissociation
  7. Emotional numbness
  8. Inability to remember aspects of, or all of the traumatic event
  9. Avoidance of anything that reminds one of the trauma
  10. Hypervigilance (Always being alert, scanning and assessing for threat)
  11. Difficulty concentrating and focusing on reality
  12. Inability to fall asleep or to remain asleep, frequent and frightening nightmares

“When I am interested with someone, to either date that person or befriend him, after a few days, all of a sudden I will shut down,” Andy said. “There are even times when I would literally run away towards the other direction.”

Studies show that trauma also causes anxiety. When there are frequent occurrence of situations related to what caused the trauma or constant exposure to trigger points – confusion and overwhelming emotional and psychological pain will set in – and these translate into anxiety.

In the Philippines, one in five people suffers from mental health problems. Between 17% and 20% of Filipino adults experience psychiatric disorders, while 10% to 15% of Filipino children suffer from mental health problems.

Dealing with trauma

“Sometimes it is better to be alone because you do not need to explain yourself or adjust to them,” Andy said.

According to the National Institute of Mental Health, there are three common ways to cope with trauma:

  1. Avoiding alcohol and other drugs
  2. Spending time with loved ones and trusted friends who are supportive
  3. Trying to maintain normal routines for meals, exercise and sleep

How long will it last? Unfortunately, there is no way to find out since it is not possible to expedite the healing process of trauma. But the intensity of emotional and psychological pain reduces with time.

“I create distractions whenever I feel I am placed inside a box,” Andy said. “Just recently, when I did something like that, the person suddenly disappeared. I was left hanging, I felt like I was all alone.”

Distractions are created by anyone to give themselves breathing space, a moment to take a step back and look at the big picture.

Knowing the other side of the story

Before dismissing someone who seems “different” in terms of how he/she deals with situations, it is better to look a little longer first.

Here are few ways you can help someone who has experienced trauma, as listed by HuffPost:

  1. Realize that trauma can resurface again and again
  2. Know that little gestures go a long way
  3. Reach out on social media
  4. Ask before you hug someone
  5. Do not blame the victim
  6. Help them relax
  7. Suggest a support group
  8. Give them space
  9. Educate yourself
  10. Do not force them to talk about it
  11. Be patient
  12. Accompany them to the scene of the “crime”
  13. Watch out for warning signs

Keep in mind that it is not your experience/story that you can freely make judgements on, else “attack” it after feeling sour.

Photo by Ian Espinosa from Unsplash.com

“Some five years ago everything fell apart with my life, in my career and health, my partner at that time chose to fool around and left me alone. It was shit. My friends told me that I was broken for four years,” Andy recalled.

That moment did not leave his mind until now. And it affected his trust issues with anything and everything.

A 2016 report by MIMS Today noted that in the Philippines, one in five people suffers from mental health problems. Between 17% and 20% of Filipino adults experience psychiatric disorders, while 10% to 15% of Filipino children suffer from mental health problems.

Unfortunately, it seems like addressing mental health is not yet among the priorities in the Philippines.

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Health & Wellness

LBG individuals use stimulants at higher rates than heterosexuals

Higher drug use among LGB individuals is likely a result of minority stress – that is, the fact that exposure to stigma and discrimination based on sexual orientation results in health disparities. Structural stigma (e.g. employment or housing discrimination) drives psychological and physical health morbidities among LGB populations, and perceived stigma is associated with cocaine use.

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Lesbian, gay and bisexual (LGB) individuals report higher rates of medical, non-medical, and illegal stimulant use compared to heterosexuals, mirroring patterns seen in other substance use.

The study by Columbia University Mailman School of Public Health researchers provides the most detailed picture to date on stimulant use by LGB subgroups and gender. Findings are published in the American Journal of Preventive Medicine.

The researchers analyzed data from the 2015-2017 National Survey on Drug Use and Health to examine associations between sexual identity and past-year use of medical and non-medical stimulants (i.e., Adderall, Ritalin) and illegal stimulants (i.e. cocaine, crack, methamphetamine). They found that bisexual women’s illegal stimulant use in the past year was fivefold that of heterosexual women (7.8% vs. 1.5%), while gay men’s use was threefold that of heterosexual men (9.2% vs. 3.2%).

Non-medical use of prescription stimulants was higher among gay and bisexual men than heterosexual men (5.4% and 6.6% vs. 2.4%) and among gay/lesbian and bisexual women versus heterosexual women (3.3% and 6.8% vs. 1.6%). Past-year medical use of prescription stimulants was higher among gay men than heterosexual men (6.6% vs. 4.1%) and bisexual women than heterosexual women (7.9% vs. 4.9%). There were no differences between bisexual men and women compared to their gay/lesbian counterparts.

Potential consequences of stimulant include substance use disorder and overdose, particularly given increases in fentanyl contamination in illegally produced pills and cocaine and methamphetamine. As many as half of LGB individuals who reported nonmedical and illegal stimulant use also reported nonmedical prescription opioid use.

“This study highlights the need for future interventions to target stimulant use among LGB populations, with a particular focus on harm reduction approaches,” says first author Morgan Philbin, PhD, assistant professor of sociomedical sciences. “The findings have important implications across sexual identities, and demonstrate the need to disaggregate stimulant use by subgroup and gender, particularly related to polysubstance use.”

Higher drug use among LGB individuals is likely a result of minority stress – that is, the fact that exposure to stigma and discrimination based on sexual orientation results in health disparities. Structural stigma (e.g. employment or housing discrimination) drives psychological and physical health morbidities among LGB populations, and perceived stigma is associated with cocaine use.

Bisexuals can also experience “double discrimination” from heterosexuals and lesbian and gay communities, which the researchers say may account for the particularly high substance use among bisexual individuals.

The paper outlines several avenues to address stimulant use, including by educating healthcare providers who focus on LGB communities to screen for and discuss substance use, including stimulants. Communities and providers can also scale-up access to medication disposal and harm reduction services.

The researchers note that their dataset started assessing sexual identity among adults in 2015, so these relationships could not be examined in earlier years or among adolescents. The options for gender included only “male” or “female” and thus did not allow researchers to differentiate between transgender and cis-gender individuals. The dataset does not assess sexual behavior, so this study only captured associations based on individuals’ sexual identity.

Authors include Morgan M. Philbin, Emily R. Greene, Silvia S. Martins, and Pia M. Mauro of the Columbia Mailman School; and Natalie LaBossier of Boston University School of Medicine.

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Health & Wellness

Sexual minority men who smoke report worse mental health, more frequent substance use

LGBTQ+ people are more likely to smoke than their cisgender and heterosexual peers to cope with an anti-LGBTQ+ society, inadequate health care access and decades of targeted tobacco marketing. Those social stressors drive the health disparities they face, which are compounded by a lack of LGBTQ-affirming healthcare providers, research shows.

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Cigarette smoking is associated with frequent substance use and poor behavioral and physical health in sexual and gender minority populations, according to Rutgers researchers.

The study, published in the journal Annals of Behavioral Medicine, examined tobacco use by sexual minority men and transgender women to better understand the relationships between smoking, substance use and mental, psychosocial and general health.

The researchers, who are part of the Rutgers School of Public Health’s Center for Health, Identity, Behavior and Prevention Studies, surveyed 665 racially, ethnically and socioeconomically diverse sexual minority men and transgender women, 70 percent of whom reported smoking cigarettes.

They found that smoking was associated with participants’ race/ethnicity, marijuana and alcohol use and mental health. Current smokers were more likely to be white and reported more days of marijuana use in the past month. The study also found that current smoking was associated with more severe anxiety symptoms and more frequent alcohol use.

“Evidence also tells us that smoking is associated with worse mental health and increased substance use, but we don’t know how these conditions are related to each other, exacerbating and mutually reinforcing their effects,” said Perry N. Halkitis, dean of the Rutgers School of Public Health and the study’s senior author.

LGBTQ+ people are more likely to smoke than their cisgender and heterosexual peers to cope with an anti-LGBTQ+ society, inadequate health care access and decades of targeted tobacco marketing. Those social stressors drive the health disparities they face, which are compounded by a lack of LGBTQ-affirming healthcare providers, research shows.

“Our findings underscore the importance of holistic approaches to tobacco treatment that account for psychosocial drivers of substance use and that address the complex relationships between mental health and use of substances like alcohol, tobacco and marijuana,” said Caleb LoSchiavo, a doctoral student at the Rutgers School of Public Health and the study’s first author.

The study recommends further research examining the social determinants of disparities in substance use among marginalized populations and how interpersonal and systemic stressors contribute to poorer physical and mental health for minority populations.

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Health & Wellness

Love hormone also forms important link between stress and digestive problems

Oxytocin, an anti-stress hormone, is released from the hypothalamus in the brain which acts to counteract the effects of stress. For a long time, the actions of oxytocin were believed to occur due to its release into the blood with only minor effects on the nerves within the brain that regulate gastrointestinal functions.

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New research published in The Journal of Physiology shows that oxytocin, known as the love hormone, plays an important role in stress’ disruption of digestion such as bloating, discomfort, nausea and diarrhea.  

Stress disrupts gastrointestinal functions and causes a delay in gastric emptying (how quickly food leaves the stomach). This delay in gastric emptying causes bloating, discomfort, and nausea and accelerates colon transit, which causes diarrhea.  

Oxytocin, an anti-stress hormone, is released from the hypothalamus in the brain which acts to counteract the effects of stress. For a long time, the actions of oxytocin were believed to occur due to its release into the blood with only minor effects on the nerves within the brain that regulate gastrointestinal functions.  

The study used new ways to manipulate the neurons and nerves (neurocircuits) that oxytocin released from the hypothalamus acts upon and measured the effects on the response of gastric emptying to stress. They have shown that, contrary to previous assumptions, these oxytocin circuits play a major role in the response of the stomach to stress.  

Activation of these oxytocin circuits reversed the delay in gastric emptying that occurs normally in response to stress, by increasing muscle contractions (motility) of the stomach, while inhibition of these neurocircuits prevented adaptation to stress.  

The new research, conducted at Penn State University- College of Medicine and was sponsored by a grant from the National Institute of Health, USA, employed cutting-edge tools that allow selective manipulation of the circuits that receive hypothalamic oxytocin inputs together with simultaneous measurements of gastric emptying and motility in response to stress.  

The authors used a rat model of different types of stress – acute stress, appropriate adaptation to stress, and inappropriate adaptation to stress. The authors infected the neurons controlling the oxytocin nerves and neurocircuits with novel viruses that allowed them to be activated or inhibited and measured muscle activity in the stomach, as well as gastric emptying (the time for food to leave the stomach).  

The researchers have shown that these oxytocin neural circuits play a major role in the gastric response to stress loads. Indeed, their activation reversed the delayed gastric emptying observed following acute or chronic responses to stress, thus increasing both gastric tone and motility. Conversely, inhibition of these neurocircuits prevented adaptation to stress thus delaying gastric emptying and decreasing gastric tone.   

These data indicate that oxytocin influences directly the neural pathways involved in the stress response and plays a major role in the gastric response to stressors. ​ 

The ability to respond appropriately to stress is important for normal physiology functions. Inappropriate responses to stress, or the inability to adapt to stress, triggers and worsens the symptoms of many gastrointestinal disorders including delayed gastric emptying and accelerated colon transit.  

Previous studies have shown that the nerves and neurocircuits that regulate the function of gastric muscle and emptying respond to stress by changing their activity and responses.  

In order to identify targets for more effective treatments of disordered gastric responses to stress, it is important to first understand how stress normally affects the functions of the stomach. Their study provided new information about the role that oxytocin plays in controlling these nerves and circuits during stress and may identify new targets for drug development. 

Commenting on the study R Alberto Travagli said: “Women are more vulnerable to stress and stress-related pathologies, such as anxiety and depression, and report a higher prevalence in gastrointestinal disorders. Our previous studies showed that vagal neural circuits are organized differently in males versus females. We are now finalizing a series of studies that investigate the role and the mechanisms through which oxytocin modulates gastric functions in stressed females. This will help to develop targeted therapies to provide relief for women with gastrointestinal disorders.”

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Health & Wellness

Notable percentage of trans men who have sex with men never got tested for HIV, bacterial and viral STIs

When considering screening for HIV and sexually transmitted infections (STIs), transgender men who have sex with men (TMSM) represent an understudied population. A study found that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs.

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When considering screening for HIV and sexually transmitted infections (STIs), transgender men who have sex with men (TMSM) represent an understudied population. A study found that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs.

In “Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men” – done by Nadav Antebi-Gruszka, Ali J. Talan, Sari L. Reisner and Jonathon Rendina, and published in BMJ Journals – researchers tried to examine HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse sample of TMSM. They used data from a cross-sectional online convenience sample of 192 TMSM, analyzed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioral factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.

The researchers found that more than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past six months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing.

Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs.

The domiciles of the TMSM also affected their health-seeking behaviors. In this study, those residing in the South of the US were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year.

Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past six months.

According to the researchers, these findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behavior.

They recommend for “efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex.”

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