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Transgender young adults (TYA) are burdened by adverse mental health outcomes. Guided by intersectionality and minority stress frameworks, we compared prevalence of psychological distress and suicidality among TYA of different social identities to inform future interventions. In this secondary data analysis of 12,738 TYA, ages 18–25 years, from the 2015 United States Transgender Survey, we developed multivariable regression models examining associations between social identities and psychological distress and suicidality, adjusting for relevant covariates. Self-reported identities were used as proxies for minority stress resulting from structural oppressions related to gender binarism, transmisogyny, heterosexism, and racism. Overall, 53% met criteria for serious psychological distress, and 66% reported suicidal ideation. Statistically higher odds of serious psychological distress and suicidal ideation and plan were found for TYA assigned male compared to assigned female at birth (adjusted odds ratios [aORs] = 1.14–1.50). Nonbinary TYA assigned male at birth also had lower odds of all outcomes compared to all other TYA (aORs = 0.6–0.7). Compared to White TYA, Latiné/x TYA were more likely to experience serious psychological distress (aOR = 1.19, 95% confidence interval: 1.02, 1.39) and multiracial TYA were more likely to report suicide plan(s) and attempt(s) (aORs = 1.25–1.30). Finally, compared to heterosexual TYA, bisexual/pansexual TYA were more likely to report suicide plan(s) (aOR = 1.28, 95% confidence intervals: 1.04, 1.52), and all sexual minority TYA were more likely to report serious psychological distress and suicidal ideation (aORs = 1.31–2.00). Results highlight complex associations between intersectional minority stress and mental health outcomes among TYA. Associations between identities and mental health morbidity highlight an urgent need for targeted mental health interventions. [ABSTRACT FROM AUTHOR]

Importance: Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown.Objective: To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes.Design, Setting, and Participants: In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019.Exposure: Recalled exposure to GICE.Main Outcomes and Measures: Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization.Results: Of 27 715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth. Among the 19 741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P < .001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors.Conclusions and Relevance: The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice. [ABSTRACT FROM AUTHOR]

Healthcare access is important for achieving health equity across vulnerable social groups. However, stigma can be a barrier for accessing healthcare among black transgender and gender diverse youth (TGDY) in the U.S. Using a resilience approach, this article examines the role of gender affirmation within healthcare to determine if it can mitigate the negative relationship between stigma and healthcare use. Data include responses from 110 black TGDY from 14 U.S. cities. Multiple logistic regression models were fit to determine relationships between stigma in healthcare (anticipated and enacted), gender affirmation in healthcare, and delayed/nonuse of primary care. Interaction terms were included to determine if gender affirmation moderates the relationship between stigma and healthcare nonuse. In the main effects model, gender affirmation was the only variable statistically associated with healthcare nonuse. The interaction between gender affirmation and enacted stigma was not significant, but gender affirmation moderated the relationship between anticipated stigma and healthcare nonuse. For individuals who did not have their gender affirmation needs met, as anticipated stigma increased, healthcare nonuse also increased; however, this did not occur for those who had their gender affirmation needs met. Findings suggest that gender affirmation within healthcare is important for increasing access to care among black TGDY. Interventions should consider how to increase gender affirmation among healthcare providers and within healthcare settings. Additional research using an intersectional approach to understand the experiences of black TGDY is needed to highlight the unique healthcare needs of this population. [ABSTRACT FROM AUTHOR]

Transgender adults may avoid medical settings due to concerns about discrimination or past experiences of maltreatment. Emerging evidence shows improved outcomes and psychosocial functioning when transgender adolescents receive gender-affirming care, but little is known about transgender adolescents' experiences in primary care. The objective of this study was to learn about the experiences in primary care of transgender and gender nonconforming (TGN) adolescents and their recommendations for primary care practices and clinicians. Participants were recruited from primary care clinics, gender care clinics, and list serves. Semistructured qualitative interviews were conducted with 20 TGN adolescents aged 13–21 years (75% white/non-Hispanic, average age 16.7 years). Participants answered questions about primary care experiences, how to improve care, suggestions regarding how to ask about gender identity, and recommendations for making offices more welcoming for TGN adolescents. Interviews were transcribed verbatim, coded, and analyzed for themes. Overall, participants reported positive experiences in primary care. Most participants commented on distress resulting from being called the incorrect name or the incorrect pronoun. Several concrete recommendations emerged from the interviews, including asking all patients about their gender identity and pronouns at every primary care visit and not asking about gender identity when caregivers are in the room. Participants emphasized the importance of using their affirmed name and pronouns and wanted providers to be knowledgeable about transgender health. Delivery of primary care services for transgender adolescents may be optimized if offices provide a welcoming environment, use correct names and pronouns, and discuss gender confidentially with patients. [ABSTRACT FROM AUTHOR]

Transgender populations are heavily burdened by HIV and other sexually transmissible infections (STIs). However, data on co-infection with HIV and STIs among transgender people are limited. A systematic review was conducted of peer-reviewed articles and conference abstracts between January 2010 and November 2015 that focussed on HIV and STI infections among transgender populations globally. The literature was synthesised and opportunities for improving health research were commented on. Few studies reported HIV-STI co-infection (n=4), while the majority of studies reported HIV and STI infections separately (n=23). Most studies were conducted outside of the USA (n=19), and all but one of these studies reported data on transgender women only. Among USA-based studies (n=8), several reported data on both transgender men and transgender women (n=3), whereas other studies reported exclusively on transgender men (n=1) or transgender women (n=4). Understanding HIV and STIs among transgender people requires research that simultaneously considers multilevel drivers of vulnerabilities. More data are needed on how the interaction of individual determinants, including biological risks of transmission, programmatic determinants such as service-delivery models and policy-level determinants including institutionalised stigma in healthcare settings, influence the HIV- and STI-related outcomes of transgender populations. Leveraging the knowledge of transgender-specific determinants of HIV and STIs should guide the content and approaches to future HIV and STI prevention and treatment efforts. [ABSTRACT FROM AUTHOR]

Objective: Examine the longitudinal association of generational status (first = child and parent born outside the United States; second = child born in the United States, parent born outside the United States; third = child and parent born in the United States) and parent and peer social factors considered in 5th grade with subsequent oral, vaginal, and anal intercourse initiation by 7th and 10th grade among Latino/a youth. Method: Using data from Latino/a participants (N = 1,790) in the Healthy Passages™ study, the authors measured generational status (first = 18.4%, second = 57.3%, third-generation = 24.3%) and parental (i.e., monitoring, involvement, nurturance) and peer (i.e., friendship quality, social interaction, peer norms) influences in 5th grade and oral, vaginal, and anal intercourse initiation by 7th and 10th (retention = 89%) grade. Results: Among girls, parental monitoring, social interaction, friendship quality, and peer norms predicted sexual initiation. Among boys, parental involvement, social interaction, and peer norms predicted sexual initiation (ps < .05). When ≥1 friend was perceived to have initiated sexual intercourse, third-generation Latinas were more than twice as likely as first- and second-generation Latinas (ps < .05) to initiate vaginal intercourse by 10th grade and almost 5 times as likely as first-generation Latinas to initiate oral intercourse by 7th grade. Conclusions: Among Latina youth, generational status plays a role in social influences on vaginal and oral intercourse initiation. Moreover, Latinas and Latinos differ in which social influences predict sexual intercourse initiation. Preventive efforts for Latino/a youth may need to differ by gender and generational status. [ABSTRACT FROM AUTHOR]

Purpose Disordered weight management behaviors are prevalent among youth; recent case reports suggested that these behaviors might also be common in transgender youth. We studied associations of gender identity with disordered weight management behaviors, nonprescription steroid use, and weight perception among transgender and cisgender (nontransgender) high-school students in Massachusetts. Methods Data were analyzed from the 2013 Massachusetts Youth Health Survey, an anonymous survey in a random sample of Massachusetts public high schools. Respondents were divided into three groups: transgender (n = 67), cisgender male (n = 1,117), and cisgender female (n = 1,289). Fisher's exact tests and multivariable logistic regression models were used to examine unhealthy weight management behaviors in the past 30 days: fasting >24 hours, vomiting, diet pill use, and laxative use; nonprescription steroid use; and self-perceived weight status. Analyses controlled for age, race/ethnicity, and body mass index. Results Compared with cisgender males, transgender adolescents had higher odds of fasting >24 hours (adjusted odds ratio [AOR] = 2.9, confidence interval [CI] = 1.1–7.8), using diet pills (AOR = 8.9, 95% CI = 2.3–35.2) and taking laxatives (AOR = 7.2, 95% CI = 1.4–38.4). Transgender youth had higher odds of lifetime use of steroids without a prescription than male cisgender respondents (AOR = 26.6, 95% CI = 3.5–200.1). Compared with cisgender females, transgender respondents had higher odds of perceiving themselves as healthy weight/underweight when they were overweight/obese (AOR = 2.4, 95% CI = 1.5–4.1). Conclusions Transgender youth disproportionately self-reported unsafe weight management behaviors and nonprescription steroid use compared with cisgender youth. Clinicians should be aware of this increased risk among transgender youth. Research is needed to further understand these disparities and to inform future interventions. [ABSTRACT FROM AUTHOR]

Background: HIV-risk resilience, or positive adaptation in the face of risk, is increasingly being recognised as an important characteristic among men who have sex with men (MSM). However, resilience in the context of online partner seeking remains underexplored among MSM. Methods: Using content analysis methodology, this study operationalised indicators of HIV-risk resilience in the profiles of 933 MSM using a sexual networking website. HIV-risk resilience included endorsing foreplay only (non-penetrative sex) or a versatile sexual position; being "out" (e.g. disclosed sexual orientation), having a profile photo, seeking friendship, seeking a relationship, serosorting, not endorsing alcohol or drug use, safer sexual adventurism (e.g. role playing, bondage), and safer sex. Results: The majority of men were between 18 and 35 years old (76.0%) and 73.3% were racial/ethnic minorities. The mean number of resilience components endorsed was 5.2 (s.d. = 1.5; range 0-9). Nearly half (48.0%) reported being "out" and 68.7% had a profile photo. The majority of men were seeking relationships (66.5%) and/or friendships (69.7%), were sexually versatile (53.3%), and preferred safer sex only (76.3%). The majority did not endorse drug use (82.0%) and 25.4% did not endorse alcohol use. Nearly one-quarter (21.4%) endorsed sexual adventurism and 2.5% were serosorting by partner's HIV negative status. Conclusion: HIV-risk resilience may be common among MSM using sexual networking websites and may manifest in safer sex intentions. Rather than exclusively focusing on sexual risk reduction, health promotion efforts targeting MSM online should acknowledge, measure, and leverage existent HIV-risk resilience strategies in this group. [ABSTRACT FROM AUTHOR]

Purpose This study investigates depression and anxiety in gender minority (i.e., transgender and/or gender nonconforming) compared with nongender minority (cisgender) young adults. Methods Data were from the Growing Up Today Study, a national cohort of U.S. young adults. A two-step method (maternal-reported natal sex in 1996 cross-classified with participant-reported current gender identity in 2010) was used to identify gender minority and nongender minority respondents (n = 7,831; mean age = 26 years). Differences in past week depressive symptoms and anxious symptoms were examined cross-sectionally by gender identity. Gender minority and nongender minority respondents were compared using age-adjusted logistic regression models. Results In gender minorities, the prevalence of depressive and anxious symptoms meeting clinical cutoffs was 52% and 38%, respectively, compared with nongender minorities (27% and 30% in females and 25% and 14% in males; p < .01). Conclusions Gender identity is an understudied social determinant of mental health. Surveillance efforts to monitor mental health disparities should include survey questions to assess gender identity in epidemiologic research. Research and interventions to understand and ameliorate mental health disparities by gender identity are needed. [ABSTRACT FROM AUTHOR]

Objective: To examine whether latent class indicators of negative affect and substance use emerged as distinct psychosocial risk profiles among HIV-infected men, and if these latent classes were associated with high-risk sexual behaviors that may transmit HIV. Methods: Data were from HIV-infected men who reported having anal intercourse in the past 6 months and received routine clinical care at 4 U.S. sites in the Centers for AIDS Research Network of Integrated Clinical Systems cohort (n = 1,210). Latent class membership was estimated using binary indicators for anxiety, depression, alcohol and/or drug use during sex, and polydrug use. Generalized estimating equations modeled whether latent class membership was associated with HIV sexual transmission risk in the past 6 months. Results: Three latent classes of psychosocial indicators emerged: (a) internalizing (15.3%; high probability of anxiety and major depression); (b) externalizing (17.8%; high probability of alcohol and/or drug use during sex and polydrug use); (c) low psychosocial distress (67.0%; low probability of all psychosocial factors examined). Internalizing and externalizing latent class membership were associated with HIV sexual transmission risk, compared to low psychosocial class membership; externalizing class membership was also associated with higher sexual transmission risk compared to internalizing class membership. Conclusions: Distinct patterns of psychosocial health characterize this sexually active HIV-infected male patient population and are strongly associated with HIV sexual transmission risk. Public Health intervention efforts targeting HIV sexual risk transmission may benefit from considering symptom clusters that share internalizing or externalizing properties. [ABSTRACT FROM AUTHOR]

Purpose Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exist to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the present study aimed to fill this gap. Methods A retrospective cohort study of electronic health record data from 180 transgender patients aged 12–29 years seen between 2002 and 2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM with MTF youth on mental health outcomes. Results The sample (N = 360) had a mean age of 19.6 years (standard deviation, 3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared with cisgender matched controls, transgender youth had a twofold to threefold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p < .05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use. Conclusions Transgender youth were found to have a disparity in negative mental health outcomes compared with cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity. [ABSTRACT FROM AUTHOR]

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI-2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender X Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. Results: Statistically significant changes in MMPI-2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity-Femininity scores (p < .01). Gender X Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men. [ABSTRACT FROM AUTHOR]

A reprint of the article "Sexual-Orientation Disparities in Substance Use in Emerging Adults: A Function of Stress and Attachment Paradigms" by researcher Margaret Rosario and others, published online on August 18, 2014 issue of the periodical is presented. It mentions a study to examine disparities in substance use by stress and attachment paradigms. The study finding reveals the importance of stress and attachment paradigms to understand sexual-orientation disparities in substance use.

Abstract: Purpose: Previous studies have found that sexual minority (e.g., lesbian, gay, bisexual) adolescents are at higher risk of substance use than heterosexuals, but few have examined how changes in sexual orientation over time may relate to substance use. We examined the associations between change in sexual orientation identity and marijuana use, tobacco use, and binge drinking in U.S. youth. Methods: Prospective data from 10,515 U.S. youth ages 12–27 years in a longitudinal cohort study were analyzed using sexual orientation identity mobility measure M (frequency of change from 0 [no change] to 1 [change at every wave]) in up to five waves of data. Generalized estimating equations were used to estimate substance use risk ratios and 95% confidence intervals; interactions by sex and age group were assessed. Results: All substance use behaviors varied significantly by sexual orientation. Sexual minorities were at higher risk for all outcomes, excluding binge drinking in males, and mobility score was positively associated with substance use in most cases (p < .05). The association between mobility and substance use remained significant after adjusting for current sexual orientation and varied by sex and age for selected substance use behaviors. This association had a higher positive magnitude in females than males and in adolescents than young adults. Conclusions: In both clinical and research settings it is important to assess history of sexual orientation changes. Changes in reported sexual orientation over time may be as important as current sexual orientation for understanding adolescent substance use risk. [Copyright &y& Elsevier]

Male-to-female transgender individuals who engage in sex work constitute a group at high risk for HIV infection in the United States. This mixed-methods formative study examined sexual risk among preoperative transgender male-to-female sex workers (N =11) in Boston. More than one third of the participants were HIV-infected and reported a history of sexually transmitted diseases. Participants had a mean of 36 (SD =72) transactional male sex partners in the past 12 months, and a majority reported at least one episode of unprotected anal sex. Qualitative themes included (a) sexual risk, (b) motivations for engaging in sex work, (c) consequences of sex work, (d) social networks (i.e., “trans mothers,” who played a pivotal role in initiation into sex work), and (e) potential intervention strategies. Results suggest that interventions with transgender male-to-female sex workers must be at multiple levels and address the psychosocial and environmental contexts in which sexual risk behavior occurs. [Copyright &y& Elsevier]

Background: Young transgender women (YTW) are a key population for HIV-related risk reduction, yet very few interventions have been developed to meet their needs. Mobile health interventions with the potential for both efficacy and wide reach are a promising strategy to reduce HIV risk among YTW.Objective: This study aims to adapt an efficacious group-based intervention to a mobile app, Project LifeSkills, to reduce HIV risk among YTW, and to test its acceptability and usability.Methods: The group-based intervention was adapted to a mobile app, LifeSkills Mobile, with input from an expert advisory group and feedback from YTW collected during user-centered design sessions. A beta version of the app was then tested in a usability evaluation using a think-aloud protocol with debriefing interviews, recordings of screen activity, and assessments of usability via the Post-Study System Usability Questionnaire (PSSUQ) and the Health Information Technology Usability Evaluation Scale (Health-ITUES).Results: YTW (n=8; age: mean 24 years, SD 3 years; racial or ethnic minority: 7/8, 88%) provided feedback on the app prototype in design sessions and then tested a beta version of the app in a usability trial (n=10; age: mean 24 years, SD 3 years; racial or ethnic minority: 8/10, 80%). Both usability ratings (Health-ITUES: mean 4.59, SD 0.86; scale range: 1-5) and ratings for satisfaction and accessibility (PSSUQ: mean 4.64, SD 0.90; scale range 1-5) were in the good to excellent range. No functional bugs were identified, and all mobile activities were deployed as expected. Participant feedback from the usability interviews indicated very good salience of the intervention content among the focal population. Participants' suggestions to further increase app engagement included adding animation, adding audio, and reducing the amount text.Conclusions: We conclude that the LifeSkills Mobile app is a highly usable and engaging mobile app for HIV prevention among YTW. [ABSTRACT FROM AUTHOR]

Background: Novel, technology-based methods are rapidly increasing in popularity across multiple facets of quantitative research. Qualitative research, however, has been slower to integrate technology into research methodology. One method, computer-mediated communication (CMC), has been utilized to a limited extent for focus group discussions.Objective: This study aimed to assess feasibility of an online video conferencing system to further adapt CMC to facilitate synchronous focus group discussions among transgender women living in six cities in eastern and southern United States.Methods: Between August 2017 and January 2018, focus group discussions with adult transgender women were conducted in English and Spanish by research teams based in Boston, MA, and Baltimore, MD. Participants were sampled from six cities: Baltimore, MD; Boston, MA; New York, NY; Washington, DC; Atlanta, GA; and Miami, FL. This was formative research to inform a technology-enhanced cohort study to assess HIV acquisition among transgender women. This analysis focused on the methodologic use of CMC focus groups conducted synchronously using online software that enabled video or phone discussion. Findings were based on qualitative observations of attendance and study team debriefing on topics of individual, social, technical, and logistical challenges encountered.Results: A total of 41 transgender women from all six cities participated in seven online focus group discussions-five English and two Spanish. There was equal racial distribution of black/African American (14/41, 34%) and white (14/41, 34%) attendees, with 29% (12/41) identifying as Hispanic/Latina ethnicity. Overall, 29 of 70 (41%) eligible and scheduled transgender women failed to attend the focus group discussions. The most common reason for nonattendance was forgetting or having a scheduling conflict (16/29, 55%). A total of 14% (4/29) reported technical challenges associated with accessing the CMC focus group discussion. CMC focus group discussions were found to facilitate geographic diversity; allow participants to control anonymity and privacy (eg, use of pseudonyms and option to use video); ease scheduling by eliminating challenges related to travel to a data collection site; and offer flexibility to join via a variety of devices. Challenges encountered were related to overlapping conversations; variable audio quality in cases where Internet or cellular connection was poor; and distribution of incentives (eg, cash versus gift cards). As with all focus group discussions, establishment of ground rules and employing both a skilled facilitator and a notetaker who could troubleshoot technology issues were critical to the success of CMC focus group discussions.Conclusions: Synchronous CMC focus group discussions provide a secure opportunity to convene participants across geographic space with minimal time burden and without losing the standardized approach that is expected of focus group discussions. This method may provide an optimal alternative to engaging hard-to-reach participants in focus group discussions. Participants with limited technological literacy or inconsistent access to a phone and/or cellular data or service, as well as circumstances necessitating immediate cash incentives may, however, require additional support and accommodation when participating in CMC focus group discussions. [ABSTRACT FROM AUTHOR]