Jennifer L. Brown1 and Nicole K. Gause2
1Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
2Department of Psychology, University of Cincinnati, Cincinnati, OH, USA
As defined by the World Health Organization (WHO), reproductive health refers to the well‐being of reproductive processes throughout all stages of life; this includes the ability to have satisfying and safe sex, as well as the ability to reproduce (WHO, 2016a). Additionally, reproductive health involves the capability to decide when and how often to engage in sexual and reproductive behaviors (WHO, 2016a). According to the WHO, to maintain reproductive health, men and women should also have access to safe, effective, and affordable contraception, as well as access to healthcare services that facilitate healthy pregnancies and childbirths (WHO, 2016a).
This chapter provides an overview of reproductive health issues that may be of clinical relevance to a health psychologist. Effective strategies for conducting sexual health histories to assess patients' sexual behavior engagement and sexual orientation are provided. Sexual behaviors that are associated with increased risk for adverse sexual health consequences such as sexually transmitted infections (STIs) and unintended pregnancies are described. Epidemiological data regarding STI prevalence is provided, as well as an overview of efficacious human immunodeficiency virus (HIV) and STI prevention intervention approaches. Modern contraceptive options that provide safe, effective methods of pregnancy prevention are discussed. Disorders related to patients' sexual health including sexual dysfunction disorders, hypersexuality, and paraphilic disorders are discussed, as well as relevant diagnostic considerations and efficacious treatment options. A brief summary of sexual behavior engagement from a developmental perspective is provided at the end of the chapter.
There is a wide variety of activities that individuals engage in to express their sexuality (Crooks & Baur, 2008). Abstinence and celibacy refer to the act of refraining from engaging in certain sexual behaviors or any sexual behaviors. Self‐stimulation of one's genitals for the purpose of sexual pleasure is a sexual behavior known as masturbation. Sexual behaviors such as kissing and touching stimulate the erogenous zones of oneself and one's partner. Individuals may also sexually stimulate a partner via oral stimulation of a partner's genitals. Terms such as oral sex (referring broadly to oral–genital stimulation), cunnilingus (oral stimulation of the vulva), and fellatio (oral stimulation of the penis) describe oral–genital sexual behaviors. Anal stimulation may involve touching around the anus or penile insertion in the anus (often referred to as anal sex). Penile insertion in a female's vagina is referred to as penile–vaginal intercourse, as well as other terms such as vaginal sex or coitus. There is great variability between individuals in how frequently these and other sexual behaviors occur; this variability may be due to a number of factors, including age and the perceived social acceptability of certain behaviors.
Furthermore, reasons for engaging in sexual behaviors may differ among individuals and even within the same individual depending on situational circumstances. People may engage in sexual behaviors in order to experience sexual pleasure, sexual arousal, or orgasm. Motivation for sexual behaviors may also involve a desire to procreate. Some individuals may engage in sexual behaviors to earn money or acquire other goods or services; prostitution is the exchange of a sexual behavior for monetary or other compensation. Unfortunately, there are circumstances under which engagement in sexual behaviors is coerced or nonconsensual (e.g., rape), a form of abuse (e.g., child sexual abuse), or a means of sexual exploitation (e.g., pedophilia). Even when sexual behavior is intended and consensual, it may have unintended consequences (e.g., unplanned pregnancy) or put one at risk for HIV and other STI.
A comprehensive general health history should include a sexual history to assess for engagement in risky sexual behaviors, as well as for potential sexual dysfunction (Peck, 2001). Structured patient questionnaires may also be incorporated into sexual histories. The core domains that should be assessed when gathering sexual history information are sexual practices (i.e., which specific behaviors the individual engages in), any concerns related to sexual functioning, information regarding sexual partners (e.g., number of partners, partners' sex(es), relationship status), use of pregnancy prevention method(s), use of STI/HIV prevention method(s), and STI and/or pregnancy history. Gathering this information requires providers discuss sensitive topics; this may make some providers uneasy or uncomfortable and result in avoidance of performing a comprehensive sexual history assessment (Peck, 2001). Provider discomfort in discussing sexual health may cause patient embarrassment or discomfort, which may in turn have a negative impact on provider–patient rapport and the accuracy of a patient's self‐reported sexual information. Furthermore, failure to perform a comprehensive sexual history assessment could interfere with patient care and may result in incorrect diagnoses or not providing appropriate referrals and treatments. In order to increase patient comfort, build rapport, and obtain the most accurate information, providers should promote open communication, emphasize confidentiality surrounding patient disclosure, employ open‐ended questions, and utilize neutral language when discussing sexual behaviors and sexual health topics (Peck, 2001).
Sexual orientation refers to the sex or sexes to which one is attracted. Although an individual may be sexually attracted to a particular sex or sexes, he or she may not necessarily identify with the corresponding sexual orientation. Further, an individual may engage in sexual behaviors that are associated with particular sexual orientations (e.g., a man who reports sex with other men), but not identify with that particular sexual orientation; in this example, this man would endorse being heterosexual as opposed to homosexual or bisexual. Some argue that sexual orientation is an aspect of an individual's broader sense of identity, which is not only based on their sexual attractions but also on group membership with others who share a similar attraction. Sexual orientation is often classified by society according to distinct categories; individuals are either heterosexual (sexually attracted to the opposite sex), homosexual/lesbian/gay (sexually attracted to the same sex), or bisexual (sexually attracted to both sexes). However, some have suggested that sexual orientation may perhaps be better understood as existing along a continuum (Crooks & Baur, 2008). For example, Kinsey, Pomeroy, and Martin (1948) proposed in their early work that sexual orientation be viewed as a range from “exclusively heterosexual with no homosexual” to “exclusively homosexual with no heterosexual” attractions and/or sexual contact.
Individuals who identify as lesbian, gay, bisexual, or transgender (LGBT) experience a variety of health disparities, including increased STI prevalence, decreased screening for cervical cancer, and experiences of abuse or violence. Knowing a patient's sexual orientation can help to identify potential areas of concern to be addressed via further assessment or treatment. Using information obtained via a sexual history assessment not only improves patient care at the individual level but also has the potential to reduce health disparities among LGBT individuals. Sexual orientation can be assessed by asking a patient whether he or she (a) identifies with a particular sexual orientation (e.g., “Do you consider yourself (i) lesbian, gay, or homosexual; (ii) straight or heterosexual; (iii) bisexual; (iv) something else; (v) don't know?”) and whether he or she (b) has any potential concerns related to his/her sexual orientation (e.g., “Do you have concerns related to your sexual orientation?”). In addition, gender identity should be assessed by asking patients about their (a) self‐identified gender identity (e.g., “Do you identify as (i) male, (ii) female, (iii) female to male/transgender male, (iv) male to female/transgender female, (v) gender queer/neither exclusively male nor female, (vi) additional/other category?”) and asking patients about their (b) sex assigned at birth (e.g., male, female). Given that the LGBT community encounters heightened stigma and discrimination, it is especially important that providers ensure patients' confidentiality and that assessment of sexual orientation and gender identity are conducted in a nonthreatening, nonjudgmental and appropriate manner.
Estimates of the number of newly acquired HIV infections per year in the United States remain relatively stable, with approximately 50,000 incident cases diagnosed annually (Centers for Disease Control and Prevention [CDC], 2015c). Globally, there were approximately 2.1 million incident HIV cases in 2015 (WHO, 2016b). Furthermore, HIV prevalence continues to rise globally, with an estimated 36.7 million people now living with HIV worldwide (WHO, 2016b). In the United States, Black/African Americans and Hispanic/Latinos have higher HIV prevalence rates as compared with other racial or ethnic groups (CDC, 2015b, 2016a). In addition, men who have sex with men (MSM) are disproportionately affected by HIV in the United States (CDC, 2015a). Unlike trends that emerged early in the HIV epidemic, US women (particularly racial/ethnic minority women) who have sex with men have also experienced increased incident HIV infections in recent years (CDC, 2016b).
In addition to HIV, there are a number of other STIs including bacterial vaginosis (BV), chlamydia, gonorrhea, viral hepatitis, genital herpes, human papillomavirus, pelvic inflammatory disease (PID), syphilis, and trichomoniasis. Negative health consequences may result from STI, and untreated STI may result in increased biological susceptibility to HIV. MSM, and racial/ethnic minority MSM in particular, experience elevated rates of STIs including chlamydia, gonorrhea, syphilis, and, as noted in a previous section, HIV (CDC, 2015a). Furthermore, individuals between the ages of 15 and 24 years of age (i.e., emerging adults), and racial/ethnic minority adolescents in particular, experience elevated rates of chlamydia and gonorrhea (CDC, 2014a).
Certain sexual behaviors, as well as substance use, may increase STI/HIV risk. For example, engaging in sex without a condom, having multiple sexual partners, or injecting drugs (and needle sharing) may increase likelihood of STI/HIV exposure. Moreover, there are structural factors that affect STI/HIV exposure risk; for example, community STI/HIV prevalence and access to adequate STI/HIV testing or treatment services as well as access to needle exchange programs affect STI and HIV prevalence. A comprehensive assessment of engagement in behaviors that increase STI/HIV risk facilitates and informs appropriate STI/HIV testing and treatment recommendations. Practitioners should assess for engagement in key behaviors that may increase an individual's STI/HIV risk; these include (a) condom use for vaginal and anal sex, (b) frequency of particular sexual behaviors (e.g., frequency of anal sex), (c) number of sexual partners, and (d) use of injection drugs and related behaviors (e.g., needle sharing). Of course, given the personal and sensitive nature of these behaviors, supplementing a face‐to‐face patient sexual history assessment interview with paper‐and‐pencil or computerized measures may enhance the accuracy of patients' self‐reported behaviors. Furthermore, focusing on shorter, more discrete time periods (e.g., “How often in the past month have you had vaginal sex without a condom?”) rather than extended time periods (e.g., “How often in your lifetime have you had vaginal sex without a condom?”) may improve the accuracy with which patients report their behaviors. Providers should deliver appropriate risk reduction counseling (e.g., encouraging consistent condom use) to patients who report engaging in sexual risk behaviors and may also want to consider further STI/HIV testing in accordance with national guidelines for high‐risk patients. For example, the US CDC recommends that all sexually active women under the age of 25 be annually screened for chlamydia (CDC, 2015d).
Behavioral intervention strategies focus on decreasing high‐risk practices (e.g., non‐condom‐protected sexual encounters and sharing of contaminated needles) to reduce and prevent the spread of STI/HIV. Indeed, there are a number of behavioral STI/HIV prevention approaches that have been reviewed, evaluated, and identified as efficacious behavioral HIV prevention interventions by the CDC (2014b). These behavioral intervention approaches utilize a variety of intervention modalities (e.g., one on one, small group) and generally target at‐risk populations (e.g., MSM, African American adolescents; CDC, 2014b). For example, HORIZONS (DiClemente et al., 2009) is an STI/HIV prevention intervention that is gender and culturally tailored for African American young women. This particular intervention includes two group‐based sessions designed to reduce sexual risk behavior engagement and incident STI among African American adolescents; results from the original randomized controlled trial indicated that HORIZONS increased condom use practices and reduced incident chlamydial infections (DiClemente et al., 2009). When used alone, behavioral interventions may reduce STI/HIV incidence, as well as engagement in risky sexual behaviors, use of contaminated needles, and other behaviors that increase STI/HIV risk.
The HIV prevention “toolkit” has expanded to include biomedical approaches as adjuncts to efficacious behavioral strategies. Biomedical HIV prevention approaches include a diverse set of strategies at different stages of product development, of varying efficacy, and at various stages of approval, including (a) microbicides that are applied to the vagina or the rectum; (b) pre‐exposure prophylaxis (PrEP) antiretroviral (ARV) medications (ARV medications for high‐risk seronegative persons); (c) post‐exposure prophylaxis (PEP) drugs (use of ARV medications following HIV exposure); (d) HIV vaccination; (e) medical male circumcision; (f) HIV testing, linkage, and retention in HIV care (“test and treat”); and (g) enhanced ARV adherence among HIV‐seropositive individuals (treatment as prevention). While the use of microbicides and an HIV vaccination have not been established as efficacious or approved for widespread use, they present possible avenues to pursue in future research; should efficacious treatments be established, they may offer additional means to curtail the HIV epidemic. Medical male circumcision, test‐and‐treat interventions, and ARV medication adherence strategies have demonstrated promise in reducing HIV transmission risk. In 2012, the US Food and Drug Administration approved Truvada (emtricitabine/tenofovir disoproxil fumarate) as a PrEP medication to be used in conjunction with safer sexual practices to prevent the spread of HIV. Combination HIV prevention approaches that integrate both efficacious behavioral and biomedical strategies may enhance the potential to reduce HIV transmission among certain high‐risk populations (Brown, Sales, & DiClemente, 2014).
There are a variety of contraceptive methods available, which may be more or less desirable depending on an individual's reproductive healthcare needs and preferences. Contraceptive methods vary in the degree of pregnancy prevention efficacy, STI prevention efficacy, and availability, which may also impact an individual's contraceptive method choices. Male condoms are effective at preventing pregnancy and protect against STI; they are widely available and do not require a prescription or doctor visit. Hormonal contraceptives include oral contraceptive pills, contraceptive patch, vaginal ring, implants, intrauterine devices (IUD), and Depo‐Provera, which consists of monthly injections. According to the American Sexual Health Association (ASHA), oral contraceptives are 92–97% effective in preventing pregnancy (ASHA, 2013); however they do not protect against STI and they require a prescription. The contraceptive patch delivers hormones transdermally; it is 92% effective in preventing pregnancy, does not protect against STI, and requires a prescription. The vaginal ring (e.g., NuvaRing) is 92% effective in preventing pregnancy, does not protect against STI, requires a prescription, and must be inserted and removed by a medical professional. Hormonal implants (e.g., Implanon) are inserted beneath the dermis by a medical professional; they are 99.99% effective in preventing pregnancy, but do not protect against STI (ASHA, 2013). Hormonal IUD (e.g., Mirena) are 99.99% effective in preventing pregnancy, but do not protect against STI; they require a prescription and must be inserted and removed by a medical professional. Depo‐Provera is a monthly injection that is 99.7% effective in preventing pregnancy, but does not protect against STI; it requires a prescription and must be administered by a medical professional (ASHA, 2013). Overall, hormonal contraceptives are highly effective in preventing pregnancy, when used correctly and consistently; however male condoms are the only form of contraception that is also effective in preventing STI/HIV (ASHA, 2013).
For over a decade, promoting the use of multiple prevention strategies (i.e., dual protection) to reduce the risk of both unintended pregnancy and STI/HIV has been recognized as “best practice” by medical practitioners and researchers (Workowski & Berman, 2006). Various protection strategies exist and can be combined to reduce both unintended pregnancy and STI/HIV, including hormonal contraception used in conjunction with correct and consistent condom use, STI/HIV screening of sex partner(s), decreasing number of sex partners, monogamy, and abstinence. These strategies, when used conjointly, enhance both pregnancy and STI/HIV prevention. Moreover, it is important to consider the unique social milieu within which these strategies occur, particularly regarding negotiation between sex partners, cost of the protection methods, potential side effects of the methods, acceptability, and other barriers.
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5; American Psychiatric Association [APA], 2013) outlines a group of disorders that are specifically related to sexual dysfunctions. These disorders are characterized by clinically significant disturbances in an individual's ability to respond to sexual stimulation or to experience sexual pleasure. The onset and frequency of a particular disturbance are important considerations in classifying a sexual dysfunction, as this information may be helpful in determining the etiology of the sexual dysfunction and appropriate treatment interventions.
Some sexual dysfunctions are gender specific, whereas others may apply to both males and females (e.g., substance/medication‐induced sexual dysfunction). Male hypoactive sexual desire disorder is a gender‐specific condition marked by a lack (either persistent absence or recurrent absence) of sexual thoughts/fantasies or a deficit in desire for sexual activity. Similarly, female sexual interest/arousal disorder includes a lack of or significantly reduced sexual interest or arousal/pleasure. Male erectile disorder is indicated by the presence of at least one of the following symptoms: difficulty obtaining an erection during sexual activity, difficulty maintaining an erection during sexual activity, or a decrease in erectile rigidity. Premature ejaculation is a persistent or recurrent pattern of early (within 1 min following penetration) ejaculation during partnered sexual activity, whereas delayed ejaculation is either a significant delay in ejaculation or infrequency or absence of ejaculation. Correspondingly, female orgasmic disorder is a delay in infrequency of or absence of orgasm or reduced orgasm intensity. Genito‐pelvic pain/penetration disorder (a female‐specific disorder) includes one or more of the following symptoms, which generally tend to be co‐occurring: (a) difficulty having intercourse, (b) genito‐pelvic pain during intercourse, (c) fear of pain or vaginal penetration, and (d) tension or tightening of the pelvic floor muscles during intercourse (APA, 2013).
According to the APA (2013), healthcare and mental healthcare providers should consider several important factors when assessing a potential sexual dysfunction: (a) partner factors (e.g., partner's sexual or health‐related problems), (b) relationship factors (e.g., discord in desires, difficulties with communication), (c) individual vulnerability (e.g., body image issues, history of sexual/emotional abuse), (d) psychiatric comorbidity (e.g., depression, anxiety, PTSD), (e) other stressors (e.g., job loss, bereavement), (f) cultural or religious factors (e.g., inhibitions or prohibitions regarding sexual behaviors, attitudes toward sexuality), (g) aging (normative age‐related reductions in sexual responses and physical activity), and (h) medical factors impacting prognosis, course, or treatment of a sexual dysfunction. Before diagnosing a sexual dysfunction, the possibility that symptoms result from inadequate sexual stimulation must be ruled out. Additionally, symptoms must be present in all or most sexual encounters (75–100% of sexual encounters), for at least 6 months, and not otherwise attributable to a nonsexual mental disorder, relationship discord, other stressors, the effects of a substance/medication, or a medical condition (APA, 2013).
Restoration of sexual functioning and the experience of sexual pleasure are the focus of treatment approaches for sexual dysfunctions. Efficacious interventions for sexual dysfunctions include cognitive behavioral therapy (CBT) (e.g., stimulus control, cognitive restructuring), behavioral therapy (e.g., systematic desensitization, relaxation), psychoeducation/sexual education, and couples therapy. A lack of sexual desire may be addressed by using cognitive restructuring techniques to explore negative attitudes about sex and replace those views with new ways of thinking about sex. Arousal disorders may also be treated with cognitive restructuring (in this case targeting beliefs about sex and sexual abilities), as well as with behavioral interventions such as relaxation, systematic desensitization, and sensate focusing. Sensate focusing involves encouraging a couple to experience pleasure from both sexual and nonsexual forms of touch. Treatments for erectile dysfunction typically target sexual performance anxiety and sexual self‐esteem. Behavioral treatments for premature ejaculation involve having a man learn to withstand stimulation and postpone ejaculation for increasingly longer periods of time; this approach has been shown to be particularly effective. Treatments for female orgasm disorders encourage realistic expectations about sexual pleasure and comfort with one's body and sexual desires, as well as gradual self‐stimulation and relaxation exercises. Relaxation training is also used to treat painful or unpleasurable intercourse that cannot otherwise be attributed to a medical condition. Pharmacological and medical interventions are also available for sexual dysfunctions; these approaches may be used in combination with psychotherapy.
In the United States, hypersexual disorder has an estimated prevalence rate of 3–6% and is thought to occur mostly in men (Kuzma & Black, 2009). The specific behaviors that are considered hypersexual and the etiology of hypersexuality are debated upon in the literature (Brown, Gause, & Garos, 2020; Moser, 2011; Winters, 2010).
Hypersexual disorder was not included in the DSM‐5 (APA, 2013); as such there are no formal clinical guidelines or diagnostic criteria for hypersexuality. However, the proposed theories of hypersexuality often include the following symptoms: a subjective loss of control; disinhibited sexual activity, which can involve culturally normative or nonnormative sexual behaviors; the presence of subjective distress; continuation of the behavior(s) in spite of escalating negative consequences; and significant impairment in areas of social, educational, occupational, or relationship functioning (Brown et al., 2020). An assessment of a potential hypersexual disorder should include a thorough sexual history, psychosocial history, psychiatric history, substance use history, relationship history, and medical history, including assessment for sexually transmitted diseases, unplanned pregnancies, abortions, and other medical conditions. In addition, it is important that the clinician assess for disorders that oftenco‐occur with hypersexual behaviors, such as bipolar disorder, anxiety, mood disorders (Kafka & Hennen, 2002; Krueger & Kaplan, 2001; Reid & Carpenter, 2009), substance abuse, and ADHD (Krueger & Kaplan, 2001), as well as other characteristics such as impulsive behavior and emotional dysregulation (Reid, Carpenter, Spackman, & Willes, 2008; Reid, Stein, & Carpenter, 2011).
The treatment of hypersexuality is often multi‐method and typically involves some form of psychotherapy. CBT is often used to identify triggers for hypersexual impulses or behaviors, manage sexual urges, and change negative, self‐defeating internalized beliefs. In addition, mindfulness interventions that teach patients to focus on the present and steer patients away from worrisome or distressing thoughts (Kabat, 1990; Kingston, Dooley, Bates, Lawlor, & Malone, 2007) are efficacious (Reid, Garos, Hook, & Hook, 2014). Treatment approaches should also include a relapse prevention component and determine if the patient's behavior puts him or her as risk for occupational, legal, health, or other severe consequences. Family and couples therapy may also be part of treatment for hypersexuality, as this disorder can have devastating effects on families and intimate partnerships or marriages. Group therapy and self‐help groups (e.g., Sex Addicts Anonymous) often augment treatment. Pharmacological medications have been shown to be efficacious in reducing sexual urges and obsessive sex‐related thoughts. Selective serotonin reuptake inhibitors (Bradford, 2001; Coleman, Gratzer, Nesvacil, & Raymond, 2000) and antiandrogens have demonstrated promising effects in reducing sexual drive and desire (Guay, 2009). These drugs may be combined with psychotherapeutic treatments that target hypersexuality.
As described in the DSM‐5, a paraphilia is “…any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (APA, 2013, p. 685). In order for a paraphilia to be considered a paraphilic disorder, it must cause an individual either distress or impairment, or be a paraphilia that entails personal harm, or risk of harm to others when or if it is satisfied (APA, 2013). Paraphilic disorders include voyeuristic disorder (sexual pleasure or excitement from spying on others in private activities), exhibitionistic disorder (exposing one's genitals), frotteuristic disorder (touching or rubbing against a non‐consenting individual), sexual masochism disorder (undergoing personal humiliation, bondage, or suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering on another), pedophilic disorder (sexual attraction toward children), fetishistic disorder (sexual attraction to nonliving objects or a highly specific sexual focus on nongenital body parts), and transvestic disorder (sexual arousal from cross‐dressing; APA, 2013). The sexual behaviors individuals with a particular paraphilia may engage in to fulfill their sexual urges or desires may pose potential harm or negative consequences to others, and they may even be classified as criminal offenses. Furthermore, it is not uncommon for multiple paraphilic disorders to co‐occur or be comorbid with other psychological diagnoses (e.g., depressive disorders; APA, 2013).
When assessing for possible paraphilic disorders, a clinician should investigate of the specific nature of the paraphilia and potential negative consequences of the paraphilia (APA, 2013). It is important to note that individuals who report a paraphilia without negative consequences, or with the potential to harm others if/when the sexual desire is fulfilled, do not meet DSM‐5 criteria for a paraphilic disorder (APA, 2013). Both clinical interviews and self‐report measures may be used by clinicians to assess for possible paraphilic disorders. CBT, intensive community supervision, and adjunctive pharmaceutical treatments (Briken & Kafka, 2007) are among the available efficacious treatments for paraphilic disorders. Pharmaceutical treatments may either lower testosterone levels or treat potential comorbid psychological conditions (e.g., depressive disorders).
Sexual activity changes across the lifespan, and sexual development varies between individuals (Crooks & Baur, 2008). Sexual behaviors that occur during childhood may include self‐stimulation of the genitals or play that may be viewed as sexual in nature (e.g., “playing doctor” with other children). During adolescence and puberty secondary sex characteristics (e.g., breasts, pubic hair) develop and result in dramatic physical changes. Sexual activity typically increases during adolescence, including both self‐stimulation behavior and sexual behaviors with partners. Engagement in sexual behavior as people age throughout adulthood varies. During older adulthood, engagement in sexual activities often correlates with sexual activity levels in earlier adulthood. Sexual activity during older adulthood may be adversely affected by co‐occurring health conditions and physical limitations.
Support provided by R03DA0377860 from the National Institute on Drug Abuse to the first author.
Jennifer L. Brown is an associate professor in the Department of Psychiatry and Behavioral Neuroscience at the University of Cincinnati. She is a licensed clinical psychologist who specializes in the development and evaluation of HIV prevention interventions. Her research aims to reduce health disparities and improve individuals' reproductive health.
Nicole K. Gause is a clinical psychology doctoral student at the University of Cincinnati. Her research and clinical interests include sexual risk behaviors among populations that are disproportionately affected by HIV/STI, substance use among HIV‐infected populations, and the etiology and treatment of substance use disorders.