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OBJECTIVE Although women account for 50% of medical school graduates, less than 30% of neurosurgery residency applicants and less than 10% of neurosurgeons are female. In order to diversify the field of neurosurgery and recruit more women, it is necessary to understand why there is a disproportionately low entry rate into neurosurgery by female medical students. Factors contributing to specialty decision-making and perceptions of neurosurgery among medical students and residents, specifically differences by gender, have not been studied. The authors aimed to investigate these differences using quantitative and qualitative methods. METHODS A Qualtrics survey was administered at the authors’ institution to all medical students and resident physicians to assess factors influencing medical specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale were analyzed with the Mann-Whitney U-test. The chi-square test was performed on binary responses. Semistructured interviews were conducted in a subset of survey respondents and were analyzed by using the grounded theory method. RESULTS Of the 272 survey respondents, 48.2% were medical students and 61.0% were female. When making specialty decisions, female medical students considered maternity/paternity leave more (p = 0.028) than their male counterparts. Female medical students were more hesitant toward neurosurgery due to maternity/paternity needs (p = 0.031) and the technical skill required (p = 0.020) than male medical students. Across both genders, the majority of medical students were hesitant toward neurosurgery due to opportunities for work/life integration (93%), length of training (88%), malignancy of the field (76%), and perceived happiness of the people in the field (76%). Female residents indicated they were more likely than male residents to consider the perceived happiness of the people in the field (p = 0.003), shadowing experiences (p = 0.019), and elective rotations (p = 0.004) when making specialty decisions. Two major themes emerged from the semistructured interviews: 1) maternity needs were more of a concern for women and 2) length of training was a concern for many individuals. CONCLUSIONS Compared with their male counterparts, female students and residents consider different factors and experiences when choosing a medical specialty and have different perceptions of neurosurgery. Exposure to and education within neurosurgery, specifically maternity needs, may help address hesitancy in pursuing a neurosurgical career among female medical students. However, cultural and structural factors may need to be addressed within neurosurgery in order to ultimately increase representation of women.

OBJECTIVE Although individuals underrepresented in medicine (URM) make up 33% of the United States population, only 12.6% of medical school graduates identify as URM; the same percentage of URM students comprises neurosurgery residency applicants. More information is needed to understand how URM students are making specialty decisions and their perceptions of neurosurgery. The authors aimed to evaluate the differences between URM and non-URM medical students and residents in terms of the factors that contribute to specialty decision-making and perceptions of neurosurgery. METHODS A survey was administered to all medical students and resident physicians at a single Midwestern institution to assess factors influencing medical student specialty decision-making and perceptions of neurosurgery. Likert scale responses converted to numerical values on a 5-point scale (strongly agree was the high score of 5) were analyzed with the Mann-Whitney U-test. The chi-square test was performed on the binary responses to examine associations between categorical variables. Semistructured interviews were conducted and analyzed using the grounded theory method. RESULTS Of 272 respondents, 49.2% were medical students, 51.8% were residents, and 11.0% identified as URM. URM medical students considered research opportunities more than non-URM medical students in specialty decision-making (p = 0.023). When specialty decision-making factors were assessed, URM residents less strongly considered the technical skill required (p = 0.023), their perceived fit in the field (p < 0.001), and seeing people like them in the field (p = 0.010) than their non-URM counterparts when making specialty decisions. Within both medical student and resident respondent cohorts, the authors found no significant differences between URM and non-URM respondents in terms of their specialty decision-making being affected by medical school experiences such as shadowing, elective rotations, family exposure, or having a mentor in the field. URM residents were more concerned about the opportunity to work on health equity issues in neurosurgery than non-URM residents (p = 0.005). The predominant theme that emerged from interviews was the need for more intentional efforts to recruit and retain URM individuals in medicine and specifically neurosurgery. CONCLUSIONS URM students may make specialty decisions differently than non-URM students. URM students were more hesitant toward neurosurgery due to their perceived lack of opportunity for health equity work in neurosurgery. These findings further inform optimization of both new and existing initiatives to improve URM student recruitment and retention in neurosurgery.

This study documents life course patterns of vicarious exposure to the criminal legal system among parents and siblings in the United States.The criminal legal system shapes family outcomes in important ways. Still, life course patterns of vicarious exposure to the system-especially to lower-level contacts-among parents and siblings are not well documented.Using longitudinal data from the Panel Study of Income Dynamics, Kaplan-Meier survival curves, and Cox regression models, we estimate cumulative risks of vicarious exposure to arrest, probation, and incarceration among parents (n=3,885 parents; 185,444 person-years) and siblings (n=1,875; 44,766 person-years) and examine disparities by race-ethnicity, gender, and education, and at their intersections.Vicarious exposure to the system is common-but highly unequal-among parents and siblings. Racially minoritized parents and siblings had greater levels and earlier risks of exposure. For example, by age 50, an estimated one in five Black parents experienced having a child incarcerated, a risk about twice as high as White and 50% higher than Latinx parents. By age 26, an estimated six in 10 Black young people with brothers experienced having a brother arrested; more than four in 10 experienced a brother on probation; and more than three in 10 experienced brother incarceration. For many estimates, racialized inequities in risks of vicarious system exposure widened at higher levels of education.These findings provide essential context for understanding the role of the criminal legal system in maintaining and exacerbating family inequality.

Stable and adequate housing is critical in the midst of a pandemic; without housing, individuals and families cannot shelter in place to prevent the spread of disease. Understanding and combating housing hardships in vulnerable populations is therefore essential to a sound public health response. This study aims to explore the pandemic’s disproportionate impacts on housing-related hardships across racial/ethnic groups in the United States as well as the extent to which these disparities are mediated by households’ broader economic circumstances; namely, their pre-pandemic liquid asset levels and the experience of COVID-19-related job and income losses. Using a national survey of over 4,000 households, we find that Black and Hispanic respondents were more vulnerable to housing-related hardships during the pandemic than White respondents. These impacts were particularly pronounced in lower-income minority households. For Black respondents, who had much lower levels of pre-pandemic liquid assets than other groups, liquid assets acted as a strong mediator of housing hardship disparities between White and Black respondents. On the other hand, neither liquid asset amounts before the pandemic nor employment shocks during the pandemic explain the pandemic’s disproportionate impacts on Hispanic families. Our findings imply that housing became less stable for racial/ethnic minority groups as a result of the pandemic. In particular, the observed disparities, as well as the mechanisms driving them, demonstrate the necessity of policies and practices that target support to these economically marginalized groups.

OBJECTIVE Female neurosurgeon representation has increased, but women still represent only 8.4% of neurosurgeons in the US. Women are significantly underrepresented as authors in neurosurgical and spine journals, a key indicator of professional success in academic medicine. In this study, the authors aimed to assess the gender diversity of first and last authors of accepted abstracts at neurosurgical conferences in 2015 and 2019. METHODS Annual meeting abstracts for 2015 and 2019 of the American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), and pediatrics, spine, stereotactic and functional surgery, and cerebrovascular AANS/CNS subspecialty sections were obtained and analyzed for gender. Partial data were obtained for tumor and pain sections. Composite gender data were obtained from the societies. Percentage differences were calculated using comparison of proportions testing. RESULTS Overall, female neurosurgeons accounted for only 8.3% of first and 5.8% of last authors, and 7.2% of authors overall. The pediatrics section had the highest proportion of female neurosurgeons as first (13.7%) and last (12.4%) abstract authors, while the spine section had the lowest proportions of female neurosurgeon first (4.6%) and last (2.0%) authors. Qualitatively, a higher proportion of women were first authors, while a higher proportion of men were last authors. Overall, there was no significant change in female neurosurgeon authorship between 2015 and 2019. With regard to society demographics, female neurosurgeons accounted for only 6.3% of AANS membership. The pediatrics section had the highest proportion of female neurosurgeons at 18.1% and the stereotactic and functional surgery section had the lowest of the subspecialty sections (7.6%). While female neurosurgeons represented 12.6% of spine section membership, they represented only 4.7% of first authors (−7.9% difference; p < 0.0001) and 2.4% of last authors (−10.2% difference; p < 0.0001). For the 2019 cerebrovascular section, female neurosurgeons were underrepresented as presenting authors (5.8%) compared with their membership representation (14.8%, −9.0% difference; p = 0.0018). CONCLUSIONS Despite an increase in the number of female neurosurgeons, there has not been a corresponding increase in the proportion of female neurosurgeons as abstract authors at annual neurosurgery conferences, and female neurosurgeons remain underrepresented as authors compared with their male colleagues.

Physical attractiveness is an important axis of social stratification associated with educational attainment, marital patterns, earnings, and more. Still, relative to ethnoracial and gender stratif...

Scholars increasingly agree that histories of racial violence relate to contemporary patterns of conflict and inequality, and growing interest exists among civic leaders in reckoning with these legacies today. This volume examines the contributions and limitations of scientific research on legacies of racial violence and suggests implications for policy, practice, and other forms of intervention aimed at redress.

Amid growing research on the history and legacies of racist violence in the United States, there has been limited development of theory and measurement pertaining to racist violence as a sociological process. Social science research has centered on lynching and, to a lesser extent, slavery and broader Jim Crow laws and customs, and rarely have these and other forms been engaged together and in relation to contemporary outcomes. We focus on racialized “legal violence”—uses of law in ways that are harmful to populations defined by race—and use the case of South Carolina “slave courts” to explore modes of racialized violence that are expansive and intertwined. Contrary to a more sequential and linear reading of successive and discreet modes of repression (e.g., “slavery ended. . .”), our analysis shows recursive, multidimensional, and cascading aspects of injurious legal action and inaction that accumulate and repeat over time. Continuities of racialized legal violence, which are contested and thus dynamic, modify and maintain age-old structural constraints. Rather than unfolding in sequence—from settler colonialism to enslavement, Jim Crow, and mass incarceration—“peculiar institutions” are more fluid, sharing repertoires and networks of racialized legal violence that recombine over time.

Popular media and researchers have given increasing attention to the perceived growing alienation and despair of white Americans. The narrative of white decline has been particularly robust in light of the recent uptick in premature deaths of whites from opioid use, but this national conversation has lacked consideration of potential associations between opioid mortality among whites and durable legacies of white advantage that were established through historical racial violence. We provide an initial analysis of how contemporary patterns of white opioid mortality in the counties of southern states relate to the presence of slavery and postbellum institutions of racial social control in those counties. We find that areas in the South with higher rates of past enslavement are associated with contemporary reductions of white vulnerability, in this case, opioid mortality. This finding supports the thesis that historical institutions of racial control offer a protective benefit within the modern white population.

Reproductive health outcomes are indicators of larger social processes and researchers have long documented inequalities in these outcomes among Blacks and Whites in the United States. However, we do not fully understand the underlying mechanisms responsible for these inequalities. We believe that this is partially due to the treatment of the Black population as a monolith, which masks underlying variation in health risks and outcomes. By examining the variation that exists beneath the average, we can begin to develop a better understanding of the potential sources of health inequalities between Blacks and other racialized populations. We provide an application of this perspective through a geographic examination of reproductive health outcomes within the Black population. Using national birth records data from 2013 to 2016, we examine differences in low birth weight, preterm birth, gestational hypertension, and gestational diabetes by nativity (i.e., US- or foreign-born), region of origin (e.g., Sub-Saharan Africa, the Caribbean), and current US division of residence (e.g., Middle Atlantic, South Atlantic) within the Black population. While foreign-born Blacks are at a lower risk for low birth weight, preterm birth, and gestational hypertension, they are at an elevated risk for gestational diabetes compared to US-born Blacks. Moreover, we find substantial variation in this general pattern across region of origin and division of residence in the US. These findings demonstrate the potential role of migration, context, and selectivity in the health of foreign-born Blacks and demonstrate that national averages mask geographic variation, limiting our understanding of the contributions of these and other social processes to the health of racialized groups in the US.

Police violence is a pressing public health problem. To gauge the illness associations of police killings – the most severe form of police brutality, we compile a unique multilevel dataset that nes...

In this Review, we assess how mass incarceration, a monumental American policy experiment, has affected families over the past five decades. We reach four conclusions. First, family member incarceration is now common for American families. Second, individuals who will eventually have a family member incarcerated are worse off than those who never will, even before the incarceration takes place. Third, family member incarceration has negative effects on families above and beyond these preexisting disadvantages. And finally, policy interventions that address the precursors to family member incarceration and seek to minimize family member incarceration would best enhance family well-being. If the goal is to help all American families thrive, then the importance of simultaneous changes in social and criminal justice policy cannot be overstated.

Incomplete documentary evidence, variable biomolecular preservation, and limited skeletal responses have hindered assessment of acute infections in the past. This study was initially developed to explore the diagnostic potential of dental calculus to identify infectious diseases, however, the breadth and depth of information gained from a particular individual, St. Louis Individual (St.LI), enabled an individualized assessment and demanded broader disciplinary introspection of ethical research conduct. Here, we document the embodiment of structural violence in a 23-year-old Black and/or African American male, who died of lobar pneumonia in 1930s St. Louis, Missouri. St.LI exhibits evidence of systemic poor health, including chronic oral infections and a probable tuberculosis infection. Metagenomic sequencing of dental calculus recovered three pre-antibiotic era pathogen genomes, which likely contributed to the lobar pneumonia cause of death (CoD): Klebsiella pneumoniae (13.8X); Acinetobacter nosocomialis (28.4X); and Acinetobacter junii (30.1X). Ante- and perimortem evidence of St.LI's lived experiences chronicle the poverty, systemic racism, and race-based structural violence experienced by marginalized communities in St. Louis, which contributed to St.LI's poor health, CoD, anatomization, and inclusion in the Robert J. Terry Anatomical Collection. These same embodied inequalities continue to manifest as health disparities affecting many contemporary communities in the United States.

Highly public anti-Black violence in the United States may cause widely experienced distress for Black Americans. This study identifies 49 publicized incidents of racial violence and quantifies national interest based on Google searches; incidents include police killings of Black individuals, decisions not to indict or convict the officer involved, and hate crime murders. Weekly time series of population mental health are produced for 2012 through 2017 using two sources: 1) Google Trends as national search volume for psychological distress terms and 2) the Behavioral Risk Factor Surveillance System (BRFSS) as average poor mental health days in the past 30 d among Black respondents (mean weekly sample size of 696). Autoregressive moving average (ARMA) models accounted for autocorrelation, monthly unemployment, season and year effects, 52-wk lags, news-related searches for suicide (for Google Trends), and depression prevalence and percent female (for BRFSS). National search interest varied more than 100-fold between racial violence incidents. Black BRFSS respondents reported 0.26 more poor mental health days during weeks with two or more racial incidents relative to none, and 0.13 more days with each log(10) increase in national interest. Estimates were robust to sensitivity tests, including controlling for monthly number of Black homicide victims and weekly search interest in riots. As expected, racial incidents did not predict average poor mental health days among White BRFSS respondents. Results with national psychological distress from Google Trends were mixed but generally unsupportive of hypotheses. Reducing anti-Black violence may benefit Black Americans’ mental health nationally.

Dramatic increases in criminal justice contact in the United States have rendered prison and jail incarceration common for US men and their loved ones, with possible implications for women's health. This review provides the most expansive critical discussion of research on family member incarceration and women's health in five stages. First, we provide new estimates showing how common family member incarceration is for US women by race/ethnicity and level of education. Second, we discuss the precursors to family member incarceration. Third, we discuss mechanisms through which family member incarceration may have no effect on women's health, a positive effect on women's health, and a negative effect on women's health. Fourth, we review existing research on how family member incarceration is associated with women's health. Fifth, we continue our discussion of the limitations of existing research and provide some recommendations for future research.

Guided by stress proliferation and adaptation perspectives, this study investigates competing hypotheses for the relationship between time served in prison and mental health symptoms. Drawing on data from the Survey of Inmates in State Correctional Facilities in 2004 (N = 12,118), our findings suggest that time served is correlated with mental health symptoms, but that the association differs across race and sex. White males exhibit fewer mental health symptoms at longer exposures to prison, while black males and black females exhibit more symptoms. We conclude that both incarceration dosage (treatment heterogeneity) and differences across groups (effect heterogeneity) may be important considerations in understanding the relationship between incarceration and mental health.

Research notes the broad complicity of white public officials in historical racial violence and repression. These discussions emphasize the role of criminal justice actors in perpetrating and enabling this repression. Extending this assessment, the authors examine coroners’ facilitation of white racial dominance through administrative performances constructing white innocence. Using cases from post-Emancipation South Carolina, the authors document race-related patterns of exculpatory effort, through the omission and curation of evidence amid the post-Reconstruction rise of white supremacist redemption. The authors theorize that these exculpatory efforts helped sustain an ideology of white innocence and institutional legitimacy by constructing a white “law-abiding” public. The authors argue that such coroner misconduct not only degrades the rule of law but has broader implications, including its corruption of the corpus of mortality and crime data. Finally, the authors suggest that these administrative performances persist in present-day coroner reporting, including in the exculpation of racist police violence.

We strongly support efforts to generate, rigorously test, and falsify hypotheses derived from the Environmental Affordances (EA) Model of Health Disparities, as originated by the late Dr. James S. Jackson (1940–2020). Such efforts are critical to establishing robust, theoretically grounded scientific frameworks that explain the fundamental causes of racial disparities in health and wellbeing. Pamplin et al. (2021) fundamentally misrepresents the EA Model as a framework that (falsely) reifies the role of race as a determinant of health behaviors and health outcomes. Further, both their study design and analytic approach are inappropriate for testing predictions of this framework. We address these issues with the goal of recentering the scholarly conversation about how stress contributes to health, and disparities in health, over the life course.

In her article “Shrinking Poor White Life Spans: Class, Race, and Health Justice," Erika Blacksher poses a provocative question: “How ought we ethically evaluate [the] life-span contraction in low-...

We use data on police-involved deaths to estimate how the risk of being killed by police use of force in the United States varies across social groups. We estimate the lifetime and age-specific risks of being killed by police by race and sex. We also provide estimates of the proportion of all deaths accounted for by police use of force. We find that African American men and women, American Indian/Alaska Native men and women, and Latino men face higher lifetime risk of being killed by police than do their white peers. We find that Latina women and Asian/Pacific Islander men and women face lower risk of being killed by police than do their white peers. Risk is highest for black men, who (at current levels of risk) face about a 1 in 1,000 chance of being killed by police over the life course. The average lifetime odds of being killed by police are about 1 in 2,000 for men and about 1 in 33,000 for women. Risk peaks between the ages of 20 y and 35 y for all groups. For young men of color, police use of force is among the leading causes of death.

Black, Hispanic/Latinx, and Native American men and women are overrepresented in the criminal justice system, including arrests, convictions, and incarceration, which means their children are also disproportionately affected. Although these disparities often motivate research on the consequences of incarceration for children and families, studies that explicitly engage with the dynamics of race/ethnicity and the criminal justice system are rare. In this chapter, we review quantitative and qualitative research that takes on the important task of understanding how parental criminal justice involvement interacts with race/ethnicity to shape children’s life experiences. We first summarize statistics on racial/ethnic disparities in the criminal justice involvement of parents. We then review research that examines whether the impact of parental criminal justice involvement varies by race/ethnicity and perspectives on why differences in the consequences may exist. Next, we consider how these disparities contribute to overall inequalities in child well-being. We consider a range of social outcomes and domains, from infant mortality to physical health and problems at school as well as avenues for future research on race/ethnicity and criminal justice system contact.

Key Points Question Is the incarceration of a family member associated with well-being and projected life expectancy? Findings In this cross-sectional study including 2815 individuals, any family member incarceration was associated with lower well-being and a projected 2.6-year reduction in life expectancy compared with no family member incarceration experience. Among those with any family incarceration, Black respondents had an estimated 0.5 fewer years of projected life expectancy compared with White respondents. Meaning These findings suggest that efforts to decarcerate may improve population-level health and well-being by reducing racial disparities and detrimental outcomes associated with incarceration for nonincarcerated family members., This cross-sectional study assesses the associations of incarceration of a family member with perceived well-being and projected life expectancy among adults in the US., Importance More than half of the adult population in the United States has ever had a family member incarcerated, an experience more common among Black individuals. The impacts of family incarceration on well-being are not fully understood. Objective To assess the associations of incarceration of a family member with perceived well-being and differences in projected life expectancy. Design, Setting, and Participants This nationally representative cross-sectional study used data from the 2018 Family History of Incarceration Survey to examine how experiences of family member incarceration were associated with a holistic measure of well-being, including physical, mental, social, financial, and spiritual domains. Well-being was used to estimate change in life expectancy and was compared across varying levels of exposure to immediate and extended family member incarceration using logistic regression models to adjust for individual and household characteristics. Data were analyzed from October 2019 to April 2020. Exposures Respondents’ history of family member incarceration, including immediate and extended family members. Main Outcomes and Measures The main outcome was self-reported life-evaluation, a measure of overall well-being from the 100 Million Healthier Lives Adult Well-being Assessment. Respondents were considered thriving with a current life satisfaction score of 7 or greater and a future life optimism score of 8 or greater, each on a scale of 0 to 10. Other outcomes included physical health, mental health, social support, financial well-being, and spiritual well-being, each measured with separate scales. Additionally, life expectancy projections were estimated using population-level correlations with the Life Evaluation Index. All percentages were weighted to more closely represent the US population. Results Of 2815 individuals included in analysis, 1472 (51.7%) were women, 1765 (62.8%) were non-Hispanic White, and 868 (31.5%) were aged 35 to 54 years. A total of 1806 respondents (45.0%) reported having an immediate family member who was incarcerated. Compared with respondents with no family incarceration, any family member incarceration was associated with lower well-being overall (thriving: 69.5% [95% CI, 65.0%-75.0%] vs 56.9% [95% CI, 53.9%-59.9%]) and in every individual domain (eg, physical thriving: 51.1% [95% CI, 46.2-56.0] vs 35.5% [95% CI, 32.6%-38.3%]) and with a mean (SE) estimated 2.6 (0.03) years shorter life expectancy. Among those with any family incarceration, Black respondents had a mean (SE) estimated 0.46 (0.04) fewer years of life expectancy compared with White respondents. Conclusions and Relevance These findings suggest that family member health and well-being may be an important avenue through which incarceration is associated with racial disparities in health and mortality. Decarceration efforts may improve population-level well-being and life expectancy by minimizing detrimental outcomes associated with incarceration among nonincarcerated family members.

A growing body of research highlights the collateral consequences of mass incarceration, including stop-and-frisk policing tactics. Living in a neighborhood with aggressive policing may affect one's mental health, especially for men who are the primary targets of police stops. We examine whether there is an association between psychological distress and neighborhood-level aggressive policing (i.e., frisking and use of force by police) and whether that association varies by gender. The 2009-2011 New York City (NYC) Stop, Question, and Frisk Database is aggregated to the neighborhood-level (N = 34) and merged with individual data from the 2012 NYC Community Health Survey (N = 8066) via the United Hospital Fund neighborhood of respondents' residence. Weighted multilevel generalized linear models are used to assess main and gendered associations of neighborhood exposures to aggressive police stops on psychological distress (Kessler-6 items). While the neighborhood stop rate exhibits inconsistent associations with psychological distress, neighborhood-level frisk and use of force proportions are linked to higher levels of non-specific psychological distress among men, but not women. Specifically, men exhibit more non-specific psychological distress and more severe feelings of nervousness, effort, and worthlessness in aggressively surveilled neighborhoods than do women. Male residents are affected by the escalation of stop-and-frisk policing in a neighborhood. Living in a context of aggressive policing is an important risk factor for men's mental health.

Purpose Pro–eating disorder (ED) online movements support engagement with ED lifestyles and are associated with negative health consequences for adolescents with EDs. Twitter is a popular social media site among adolescents that provides a unique setting for Pro-ED content to be publicly exchanged. The purpose of this study was to investigate Pro-ED Twitter profiles' references to EDs and how their social connections (followers) reference EDs. Methods A purposeful sample of 45 Pro-ED profiles was selected from Twitter. Profile information, all tweets, and a random sample of 100 of their followers' profile information were collected for content analysis using the Twitter Application Programming Interface. A codebook based on ED screening guidelines was applied to evaluate ED references. For each Pro-ED profile, proportion of tweets with ED references and proportion of followers with ED references in their own profile were evaluated. Results In total, our 45 Pro-ED profiles generated 4,245 tweets for analysis. A median of 36.4% of profiles' tweets contained ED references. Pro-ED profiles had a median of 173 followers, and a median of 44.5% of followers had ED references. Pro-ED profiles with more tweets with ED references also tended to have more followers with ED references (β = .37, p Conclusions Findings suggest that profiles which self-identify as Pro-ED express disordered eating patterns through tweets and have an audience of followers, many of whom also reference ED in their own profiles. ED socialization on Twitter might provide social support, but in the Pro-ED context this activity might also reinforce an ED identity.