Migration exposes Central American migrants, particularly those who migrate without documents, to a range of incidents, dangers, and risks that increase their vulnerability to anxiety symptoms. In most cases, the poverty, conflict, and violence they experience in their countries of origin are compounded by the unpredictable conditions of their journey through Mexico. The objective of this study was to explore the association between the presence of emotional discomfort and the experience of various vulnerabilities from the perspective of a group of Central American migrants in transit through Mexico. This is a descriptive, mixed-methods study (QUALI-QUAN). During the qualitative phase, thirty-five migrants were interviewed (twenty in Mexico City and six in Tijuana). During the quantitative phase, a questionnaire was administered to 217 migrants in shelters in Tijuana. An analysis of the subjects’ accounts yielded various factors associated with stress and anxiety, which were divided into five main groups: (1) precarious conditions during the journey through Mexico, (2) rejection and abuse due to their identity, (3) abuse by Mexican authorities, (4) violence by criminal organizations, and (5) waiting time before being able to continue their journey. The interaction of various vulnerabilities predisposes individuals to present emotional discomfort, such as anxiety. Migrants who reported experiencing three or more vulnerabilities presented the highest percentages of anxiety symptoms.  In the 1980s, emigration from countries such as Honduras, Guatemala, El Salvador, and Nicaragua ceased to be intraregional, focusing instead on the United States and Canada. People no longer left their countries of origin for purely economic reasons but were forced to migrate. These changes were caused by the dynamics of inequality and social breakdown, resulting from socioeconomic deterioration and the increase in structural violence committed by criminal groups, exacerbated by the indifference of the region’s authorities. One of the immediate repercussions of these situations on the population has been the increase in emigration . The majThese adverse conditions can be exacerbated by criminal activities targeting migrants or the extreme weather conditions in northern Mexico. All of the above are potential risks that occur during the journey of those entering the south of the country seeking to reach the United States border. In a study of migrants, González and Aikin  identifiTo this end, we take up the proposal of “accumulated vulnerabilities,” through which the convergence of two or more adverse circumstances is analyzed at certain points in time . The anaDifficulties encountered along the way include the stiffening of securitization and containment policies in Mexico and the United States. The first consequence of these policies has been an increase in the number of arrests and deportations of people lacking the necessary documentation, exposing them to abuses and violations of the rights of migrants by Mexican authorities ,11,12,13The next consequence of containment policies is that to avoid immigration controls, people on the move are forced to travel along more dangerous routes since, in the first instance, the supply of basic resources for survival, such as water, food and shelter, not to mention medical aid ,15, is nAt the same time, it has been documented that on these alternative routes, migrants are more exposed to the activities of criminal groups ,16. A reAnother consequence of border outsourcing policies, compounded by the implementation of Title 42 due to the COVID-19 pandemic in 2020, is that migrants’ stay in Mexico is longer than they had anticipated. This permanence has been called “forced immobility” or entrapment ,18. DuriThese situations affect the mental health of people on the move in a variety of ways and to differing degrees. Symptoms ranging from worry, emotional discomfort, and anxiety to post-traumatic stress disorder have been reported. Temores-Alcántara et al.  reportedWillen et al.  pointed A prolonged or longer-than-expected stay in the country of transit increases the probability of presenting emotional discomfort. Requena et al.  found thDuring the time migrants are forced to remain in a town or city, they seek accommodation in shelters or temporary settlements and rely on food either from these shelters or charities ,18. ThesThe objective of this study was to explore the relationship between the presence of emotional discomfort and the experience of various vulnerabilities from the perspective of a group of Central American migrants in transit through Mexico. Emotional discomfort is understood as the perception of moods a person recognizes and expresses, such as worry, sadness, anger, fear, stress, and anxiety. → QUAN) was used [This is a descriptive exploratory study in which a mixed methods model  mFor the data obtained from the survey, descriptive analyses were performed. The statistical analysis was conducted using the SPSS 21 and STATA 13 programs. Because the sample size of LGBTI migrants was small and did not allow for statistical analysis, this group was not included in the quantitative results. However, some of their narrations were subsequently revisited.For the description of vulnerabilities, the following categories were established: 1. Precarious conditions during the journey through Mexico: Refers to the lack or insufficiency of money and, therefore, food, water, and other supplies during their journey. This was compounded by limited access to basic services such as accommodation, toilets, showers, and medical care, as well as the lack of immigration documents and information on transit routes, human rights, and administrative processes.2. Rejection and abuse because of their identity: Includes factors related to gender-sex identity, socioeconomic class, ethnonational characteristics, and undocumented status.3. Abuse by Mexican Authorities: Refers to economic extortion, mistreatment and non-compliance with the legal framework, or violations of the provisions enshrined in migration laws by immigration authorities, federal and state police, and the army.4. Violence by criminal organizations: Acts performed by these organizations with varying degrees of violence . 5. Waiting time before being able to continue their journey: The period when migrants must remain in a town or city due to factors curtailing their desire to move. The research was approved (CEI/C/061/2020) by the Research Ethics Committee of the Ramón de la Fuente National Institute of Psychiatry (IRB00006105). It was considered a minimal-risk project, so informed consent was obtained verbally. In both phases, authorization was requested from each of the subjects, who were informed of the objectives of the project, the data collection techniques, and the confidential nature of the information. Authorization to release the information was also requested.Results were organized according to the five vulnerabilities identified, and in each one, extracts from the subjects’ remarks are presented, together with graphs showing the survey data. Most subjects remarked that they had left their place of origin in a hurry, without being able to raise enough money or prepare for the trip by stocking up on the necessary supplies. Nor did they have sufficient information about the unpredictability of the trip. When they entered Mexico, they were forced to walk for hours in the hot sun without proper footwear. They reduced their food and water consumption, and some remarked that they had been forced to spend the night outdoors without warm clothes or blankets. After spending many days under these conditions, they said they felt significant physical wear and tear. Mario, a Honduran, summed this up as follows, “The road is very rough, it’s hard on your feet, and there is a lot of tiredness and dehydration”.According to the subjects, the lack of money is a constant because not having immigration documents makes it extremely difficult for them to secure employment. For example, regarding accommodation, the majority said that they were forced to alternate periods living in shelters with periods living on the streets. These precarious conditions were also observed in the responses to the survey on food insecurity ). In this respect, 35% of migrants reported that they had not eaten for a whole day during their last stay in Tijuana, while 58.8% declared that they had stopped eating breakfast, lunch or dinner. These data reflect a severe level of food insecurity. Moreover, one in six migrants stated that they had eaten less than they should have, placing them in the category of medium or moderate insecurity see .Subjects associated food deprivation with negative moods or emotions such as “depression” and constant “worry”. Apropos of this, Samuel  remarked: “You get depressed because you don’t have the money to buy a plate of food, because you can’t afford to buy a plate of food. You are worried because there are times when there is none. And there is also a problem of work, which means you can’t buy what you need, personal items for yourself.”For those traveling with small children, the lack of food was an even more pressing problem. Edgar, a Honduran, shared the following: “Yesterday I went out to cry in the corner over there, outside the shelter, because at home, for as long as I can remember, there has always been a fruit basket in the middle of the table in my house… but now we are here, yesterday I did not have a penny in my pocket, I was trying to get milk for my children…With five children it is not easy, you have to take care of them.” The lack of money that caused housing problems and food deprivation created a state of permanent vulnerability for the subjects, which was compounded by another condition with a negative impact: their identity characteristics. Gender-sex identity, socioeconomic class, nationality, ethnicity, and undocumented status are characteristics that caused migrants to experience stigma, rejection, and even abuse and violence. These attitudes were displayed by Mexicans, other migrants, and even the staff of institutions related to migration issues. Regarding nationality, some subjects reported that in various places they had passed through, those with eateries, bathrooms or showers, or motorcycle taxi drivers charged them more than they did Mexicans. Omar, a Honduran, said that “in the place we were renting, because we were migrants, it was quite expensive. We had some neighbors who were Mexican, and they paid about $1200 pesos, but we were charged $2500.”Regarding the rejection due to gender identity, those who experienced it repeatedly and most aggressively were transgender women, who recounted incidences of discrimination and mistreatment. Ana (a Honduran) mentioned the following: “I think that in Mexico I have had a lot of discrimination. I felt bad because… I came supposedly to look for a new life in Mexico to feel good. They had told me that there was no discrimination here, but I have suffered a lot of discrimination, I went to work but they didn’t gave me a job because I was trans.”Verbal attacks and mistreatment due to their skin color and ethnic characteristics were experienced by men and women of any age, including children. Jordán (a Honduran) remarked, “Many Mexicans are good, but some are racist. They treat you badly, and they call you a ‘bloody raccoon from Honduras or trash’ and that makes you feel bad.” Esperanza (a Honduran), who is the mother of two children, said that she felt “depressed” because “... I have two children who are black and they are the only blacks and they treat them very badly. They say things to them and we hear them but we don’t say anything because after all, I am not in my country.” When the interviewees narrated these experiences and were asked how they had felt, the most common answer was “bad.” When asked to be more specific, they said they felt “sad”, “angry” or “awful”. In the survey, being rejected due to their identity was explored through the question: “Have you suffered discrimination because of your religious beliefs, practices or sexual preferences?” Overall, 19% of men and 17% of women reported having experienced this type of discrimination . One of the factors contributing to the gradual impoverishment of those interviewed who were in transit in Mexico was the repeated extortion they suffered by federal and local police, immigration agents, and members of the army located at various checkpoints along the migratory routes. This extortion occurred even when they traveled on commercial buses, colloquially known as “commercial” buses. “I think the biggest barrier I have had in Mexico is the police. Yes, they have taken a lot of money from me, the truth is, just to get there, from Hidalgo to Tapachula, how much is that, an hour’s drive? I think they took about twelve thousand pesos from us......to be able to cross into Huiztla, we had to go through three checkpoints and at each checkpoint they took almost 500 pesos from each of us. And that happened even though we were in the COMAR (Mexican Refugee Aid Commission) process. And even though we were told we could go anywhere we wanted in Chiapas” .Subjects also noted that the authorities frequently ignored, stole, or tore up their humanitarian visas, the permits enabling them to move around the country or authorizing their temporary stay there, issued by Mexican institutions, and which they carried with them. “In Querétaro, when we come here…(Tijuana) we also suffered discrimination from the Mexican authorities, who told us that these documents are false (humanitarian visa), and “if we wanted to continue, we had to give them a thousand pesos per head, when we didn’t have any money at all”, Dahlia (Nicaraguan). Another sensitive issue was the physical mistreatment and sexual abuse suffered or witnessed by subjects during the searches conducted by the police of commercial bus passengers. “…they are with the patrol cars there, and that is when they take the opportunity to get on the bus, take bribes, rob, scam people… a woman sitting next to me had her daughter with her. Both of them were asleep and the officer woke them up. He even checked her private parts, her boobs and all those parts. He began to rummage around, he put his hand down her pants…” Ruth (Honduran).In the survey administered to migrants, this type of abuse was also explored. A total of 42.2% answered “yes” to the question: “Did you suffer any abuse of authority by immigration agents, police, soldiers, marines, etc.?” A total of 38.4% declared that they had been detained for no reason by an immigration or police authority, while 26.5% stated that the immigration authorities had refused to provide support see . In addition to this “institutional” violence by the Mexican authorities, there is the risk of becoming victims of organized crime in Mexico.In the course of the interviews, we heard reports of this type of violence, and the most recurring sensation or impression in the people who underwent or witnessed them was fear, in addition to other conditions such as the one reported by Salma, the mother of a girl who was assaulted. “We were groped, they groped us, they asked us for everything…they threw us into a ravine, as a result of which my daughter has psychological traumas. Those vandals held a gun to her (pointing to her head)…” Salma (Honduran). Subjects who did not directly experience or witness a violent act also said that they felt fear or “nerves” at the possibility of being extorted or attacked by organized crime. Joan, a Honduran, expressed it as, “... mistreatment on the way, a form of kidnapping…”Carola (Honduran) also remarked that she is frightened when her husband leaves the shelter, “…I’m scared something will happen to him in the street, that they are going to kidnap him because they say that many people are being kidnapped and so on. People are nervous that could happen to them there.” The survey data confirm how vulnerable migrants are. As shown in graph 4, over fifty percent experienced this situation during their journey through Mexico. The main types of violence were robbery or assault. They were asked for money or something else and received threats. Men received more threats. Thirteen percent were kidnapped at least once .This contributed to the perception of being permanently in an unsafe context, coupled with the impossibility of leaving or moving elsewhere.For the subjects, having to spend a long time in a place that was not their final destination made them feel “trapped”, “immobilized”, and “on standby”, which produced “stress”, “sadness”, “helplessness”, “worry” or “anger.” “…You feel alone, and shut in, plus the stress of (not knowing) when are you going to leave, when you are going to have your turn, not having any money. Maybe you want to have a soda and if you don’t have friends here, nobody is going to invite you. These are things that make you feel stressed and powerless and vulnerable. You feel tired, you don’t want to go on…” .As part of the survey, subjects were asked when they had arrived in Tijuana. Of the total number of subjects, 57.3% had spent less than three months there at the time of the interview; 33.2% had arrived six months earlier, and 9.5% had been stranded in this border city for more than six months. As shown in An association was found between accumulated vulnerability and anxiety symptoms. We confirm that the interaction of various vulnerabilities predisposes individuals to health problems, in this case, emotional discomfort such as anxiety.In this respect, it was observed that migrants who reported experiencing three or more vulnerabilities presented the highest percentages of anxious symptoms. It is interesting that in the case of men, having two vulnerabilities suffices to triple the prevalence of anxiety, whereas, for women, the presence of three or more vulnerabilities is required to triple this prevalence .Of the five vulnerabilities we identified in our work, four coincide with the risks recognized by González and Aikin . This meAfter exploring the migration trajectories of the subjects, we considered that the vulnerability that largely determines the way they experience transit through Mexico is “precarious conditions”. These conditions are linked to the reasons they cited for their departure from their countries of origin, which the literature describes as the effects of the persistent inequality and socioeconomic deterioration of the region’s populations ,2). ThisIn regard to the vulnerability caused by “rejection and abuse due to their identity”, and according to the contents of the interviews, as well as the survey, we can confirm that discrimination is present in the experiences of migrants. As González and Aikin  noted, cFrom the perspective shared by the subjects and in keeping with what Quesada et al.  propose,In addition to the above, when the subjects were in “forced immobility” or entrapment , some asStudies conducted on the general population have also shown that the likelihood of the onset of mental disorders, including anxiety disorders, rises as the number of adversities or vulnerabilities increases. However, they have also pointed out that there are vulnerabilities that have a greater impact than others and that certain associations are riskier ,29. In sAs observed in the prevalence of anxiety symptoms and accumulated vulnerability, there is a significant difference by sex. A possible explanation could be found in what was stated by Herrera and Campero , who poiThe use of a mixed methods model made it possible, on the one hand, to describe how a group of migrants accumulate vulnerabilities related to precariousness, identity, institutional abuse, criminal violence, and forced immobility while they are in transit through Mexico and identify which emotional discomforts each of these adversities caused them. At the same time, and based on the statistical data, the model enabled us to state that this type of experience is not exceptional but instead recurrent among Central American migrants. The direct association between mental health and the accumulation of vulnerabilities for a population group could therefore be considered a problem that should be addressed in the public mental health field. We confirm the idea expressed by Dahlgren and Whitehead  that pubAlthough not all migrants who experience these vulnerabilities and anxiety symptoms will develop a severe mental disorder, most of them require humanitarian care to meet their everyday needs, while a significant proportion require psychosocial intervention. We believe that some of the strategies proposed by the Lancet Commission on Global Mental Health  can be aThe implementation of actions such as these decreases the likelihood of mental disorders occurring or becoming chronic in cases that already had a disorder before migrating. Limitations of the study include the fact that results cannot be generalized to all Central American migrants in transit through Mexico since they only correspond to a specific group housed in shelters in Mexico City and Tijuana. Migrants not living in these shelters may share some of the same vulnerabilities but might also face others not explored in this article. Likewise, we consider that although the research investigated a significant number of vulnerabilities, it did not examine all those that may be related to the presence of emotional disorders.


Diversity in aging has received increased attention in recent years in the field of gerontology. However, older lesbian, gay, and bisexual (LGB) people have largely been missing from these conversations. In this study, I examine older LGB people’s subjective views on the aging process, focusing specifically on visions of late life.Life story interviews were conducted with 60 LGB individuals over the age of 55 who reside in the Southeastern and Midwestern portions of the United States. Inductive coding  and analyses were conducted.Four major themes emerged from the data: (1) financial distress linked to past events of homophobic discrimination, (2) anxieties regarding staying in paid care settings, (3) desires to age in place or “in community” with other lesbian, gay, bisexual, transgender, and queer people, and (4) a prioritization of quality of life over longevity via plans to pursue assisted suicide.The findings of this study suggest that views of aging and visions of late life are tied to social group membership, highlighting the need for gerontologists to further consider cumulative inequality processes. The study also offers evidence of queer aging, wherein queer culture, history, and experience produce distinct meanings of aging. Translational Significance: Heightened aging-related challenges were reported in a qualitative sample of older lesbian, gay, and bisexual (LGB) individuals. Understanding older LGB people’s fears about aging and the utilization of paid care services is necessary in order to improve the quality of care that this population receives in late adulthood. In particular, staff in health care settings and long-term care homes should be educated on how to provide culturally competent care, including the usage of inclusive terminology.There are at least 2.7 million lesbian, gay, and bisexual (LGB) adults over the age of 50 in the United States, and this number is expected to reach nearly 5 million in the next few decades . Yet, olI begin by describing issues that generally accompany the aging process. Poverty is not uncommon in late adulthood, due to a loss of income as a consequence of retirement; similarly, individuals may not have adequate savings for their retirement years . In addiScholars in recent years also investigate diversity in aging, emphasizing that gender, race, and social class shape aging experiences . Centralqueer aging to suggest that the meaning of aging among LGB adults may be distinct , the current manuscript primarily utilizes the data that pertain to expectations regarding late life. I also probed participants when their responses were too brief. Interviews lasted roughly 1.5 hr and were audio-recorded with permission from participants.I collected life story interview data during the summers of 2018 and 2019. This interviewing technique is used to gather information on a person’s life over time and pushes researchers to consider how surrounding historical contexts shape people’s lives . InterviEligibility requirements included being 55 and older, identifying as lesbian, gay, bisexual, or queer, and residing in the Southeastern and/or Midwestern regions of the United States. The study focuses on these geographic regions because far less is historically known about older LGB people from these areas of the country. I selected participants 55 and older because these generations of LGB people were born prior to Stonewall, the beginnings of the gay-rights movements, and thus came of age prior to the growing acceptance of LGB individuals in U.S. society. The sample includes both members of the boomer and silent generation with the former coming of age during a period where LGB people experienced increased visibility, due to the Stonewall Riots. In contrast, the silent generation lived through the McCarthy era, facing fears of having their sexual identity publicly disclosed without their consent; LGB people were also often marked as criminal and as mentally ill during the time the silent generation came of age .Transgender and nonbinary individuals were intentionally omitted from the study, as their experiences are qualitatively different from LGB people; gender-based concerns may instead drive their current aging experiences, which would have required that a different set of interview questions be asked. Simultaneously, there may also be overlap in cisgender LGB and transgender people’s visions of late life, an issue I return to in the discussion section.Because older LGB adults are a hard-to-reach population, I relied on non-probability sampling methods  to recruit the participants; this method is consistent with most studies of this population . I also Most interviews were conducted in person or by phone in the Southeast and Midwest. Flyers containing study information were also hung at houses of worship, coffee shops, bars, etc. in a Southeastern state to recruit a diverse array of people. In addition, I recruited from social spaces from the LGB community, including online, community-based organizations, LGBTQ centers, senior centers, and retirement communities that specifically serve older LGBTQ people. I also identified gatekeepers for the study at local organizations, who helped recruit participants.line-by-line coding to identify patterns in the data that are not yet apparent and focused coding to collapse some of the overlapping themes into more general categories . Ninety-three percent identify as gay or lesbian, while 7% are bisexual or queer. Sixty percent were married or partnered, and 35% of the sample have children. The sample is also highly educated insofar as 70% of the sample hold at least a bachelor’s degree. Moreover, the sample is largely nonreligious (61%).Participants were asked to describe challenges facing older LGB adults, and financial distress was repeatedly named as an issue among both generations. Although poverty is common in late adulthood, it is potentially worsened by homophobic discrimination. Incidents of being denied a job and threats of being fired were faced by numerous participants. Betty  described an incident of being denied a job at a reproductive care center, noting that HR informed her that her sexual identity was an impediment to effectively doing her job. She elaborated that HR blatantly stated that she is “going to have a really hard time finding a job in Kansas City,” due to her sexual orientation. Similarly, Fred  reported that a supervisor informed him, “I’m sorry, but I [have to] let you all go … you’re too gay.” Homophobic discrimination also affected performance reviews, which has implications for promotion and salary. Dawn  noted that homophobic bias shaped her performance review as a teacher. She revealed that her supervisor accused her of being too close to a female student, an incident she interpreted as laden with homophobic biases.Participants’ narratives revealed that discrimination has long-term consequences on their lives, especially financial stability. Dave  noted:Gay people have never had the advancement in jobs and all of that because of who they were … They have not built IRAs or thought about it until we were in our late 40s … we know people that just are going by the skin of their teeth. They’re on food stamps, and their job never paid enough for them to accrue anything for retirement, and their social security certainly is not good.Similarly, Joseph  revealed that, due to a lack of promotions and bonuses, “saving was not something they  could do because they could hardly live just on what they were getting. So, they enter the area of a timeframe in their lives where they don’t have the finances....” Others similarly shared that, due to a lack of stable and prosperous jobs, savings are limited. The effects of homophobic discrimination compounded, leading to further financial distress in late adulthood. Participants also later revealed that financial distress compromises their ability to pay for long-term care, a point I later revisit. Here, it becomes apparent that risks encountered earlier in life worsen well-being later in life, consistent with cumulative inequality theories . These fSome variation in exposure to discrimination and subsequent financial distress was also documented among participants. Boomers were more likely than the silent generation to emphasize that discrimination in jobs and promotions over time led to financial distress, which may be due to higher rates of disclosing their identity as an LGB person. Surprisingly, married and partnered people were also twice as likely to report fears of financial distress than singles, despite the fact that they often possessed two sources of income. One possible explanation for this finding is that their partnership status rendered their sexual identity visible, making them more vulnerable to facing homophobic discrimination.make sense of end-of-life care plans potentially differs. Patricia  asked, “… How we would be treated by the staff …? You know, would we get comments? Would we get treated differently than the other people would? [Would] other members of the community treat us poorly?” Others echoed Patricia’s concerns about the possibility of unequal treatment. Mark  regularly asked himself, “What if I go into a nursing home and what if they’re homophobic? Do I go back into the closet?” Here, Mark’s concerns centered on fears that he will need to conceal his identity as a gay man, not unlike how he did in earlier decades when homophobic attitudes were more rampant. Being closeted also results in a loss in feelings of autonomy, a positive view of one’s identity, and freedom of sexual expression; accordingly, one jeopardizes their right to feel mentally and physically safe at the end of life if having to conceal one’s identity  expressed fears that predominately heterosexual nursing homes would be comprised of individuals who “lived in an era where it wasn’t cool to be gay.” He elaborated that LGB people were viewed as mentally ill during earlier periods, which he believed would affect the attitudes of older, heterosexual residents. In addition, Kathy  remarked that “guys with AIDS have gone through absolute hell having to live in these facilities” when asked about her thoughts on staying in a paid care setting. She elaborated that they have been physically assaulted by nurses and expressed doubts that older LGB people would receive adequate care. Thus, the historical legacy of medical mistreatment of the LGBTQ community looms large and casts doubt on medical staff’s ability to provide equitable care and treatment. In short, participants wished to avoid retraumatization in medical settings .Finally, similar to the experiences of heterosexual individuals, participants’ concerns about utilizing paid care were driven by financial instability . Beth 7.Participants emphasized that they wished to age in community with one another or minimally with LGBTQ-friendly people in shared residences and long-term care homes; this departs from heteronormative  understandings of aging with a predominate reliance on biological family for care. Hong  noted that he hoped to stay in a gay-friendly long-term care home in order to avoid any potential instances of inadequate care, due to discrimination. In addition, participants also desired to live in gay neighborhoods and shared living situations, including private homes in gay neighborhoods for those who are 55+, and/or shared houses. Frank  currently resides in one of the only gay neighborhoods for 55+ people in the country. He noted that many members of his community intentionally left homophobic areas where they were “afraid to come out to people” and now embraced an opportunity to be away from individuals in their age group who are homophobic. Aging in gay-friendly communities may also ensure that participants can avoid the concealment of their identities and secure social support that is pivotal for reducing risks of social isolation, loneliness, and depression that are commonly experienced among older LGB adults .interdependent approach to care. Lorena  and Judy  both described nearly identical visions, expressing plans to build a cooperative living arrangement where women congregate, share land, garden, and provide care for each other. Similarly, Jackie  wished her current 55+ gay-friendly neighborhood would further evolve, and stated that she would like “to be able to have somewhere where you could go to the big house. You could have a shared dinner meal … if you’re in trouble, you can call somebody and they’re there.” Moreover, Jackie also emphasized that gays and lesbians have historically “had to take care of each other...we had to stay together because no one else would.” Thus, queer history is referenced in these visions of interdependent care  echoed this sentiment, remarking that the absence of biological family results in older LGB people turning to friends for care.interdependency and a rejection of heterosexual models of care that typically include a heavy reliance on biological family and children.However, the ability to age in place may not always be possible, as social isolation  leaves some older LGB adults unable to live at home. Consistent with prior literature , particiOlder LGB people also expressed a strong desire for quality over quantity of life in late adulthood. Participants, specifically, named assisted suicide as one possible method to opt for quality over quantity of life should they no longer be able to provide care for themselves. Chris  remarked, “If I got to the point where my life was not … enjoyable … if I got bedridden or something like that I’m ready to go. I don’t want to live like that. I don’t want to live in a bed. I don’t want to live on a machine … I would probably want to end my life myself.” Chris, similar to other participants, later elaborated that he is unable to accept what he perceives as a low quality of life, including an inability to complete basic bodily functions . Similarly, Bill  remarks:… I do believe that people should have the right to end their life ... You know, I don’t consider myself suicidal, but … people should have the dignity to live their life to the fullest. And when they feel like they have no dignity, I think they should have the right to say, ‘You know, I’d like to have some medication and go to sleep.’ I mean, that’s what I would want.The belief that one has the right to terminate their own life emerged across a range of participants.As previously discussed, participants feared having to go back into “the closet” or facing abuse if staying in long-term care homes. Joe  described LGB people’s experiences in medical facilities, noting that a number of staff “were abusive, and that a lot of the people who are residents are unaccepting.” Joe added that he is “not interested in that environment and if it gets to that point, I’d rather just kill myself.” Gloria  also noted that she and her friends have decided that they will kill themselves before being willing to enter a nursing home. She described abusive conditions, remarking: “I’m not going to be out of it in a nursing home where you’d be drugged even more and maybe restrained and people not change you. I love life, but that’s not the life I want. That’s because they can extend life beyond what’s quality of life. And I don’t believe in that.” Here, we see that fears of ageist and homophobic abuse are prevalent among older LGB people, which push them to consider assisted suicide.meaning of older LGB adults’ aversion to staying in long-term care homes and subsequent preference for “aging in place” is also distinct. Participates indicate a desire to age “in place” and “in community” with the help of similar others, consistent with a tendency in queer cultures to embrace interdependent approaches to care through a reliance on chosen family. Finally, some participants discuss a desire to pursue assisted suicide, challenging mainstream values about living a long life.Using life story interview data, I offer a further articulation of “queer aging,” demonstrating that older LGB people’s visions of late life are driven by queer culture, history, and experience. Although there are some shared features of aging experiences  by older adults, irrespective of sexual identity, older LGB people’s visions of late life also diverge in significant ways. Some evidence in support of cumulative inequality theories emerges, as participants reported facing heightened financial challenges in late adulthood. The This article offers some evidence of cumulative disadvantage processes among older LGB adults, filling a key gap in the literature . ParticiSimultaneously, participants’ visions of late life were laden with themes of resiliency and desires to adopt creative solutions for combating homophobic-related challenges that arise in long-term care homes; participants, specifically, mentioned that they will instead turn to other LGB people to age “in community” or “in place.” A tendency to be inventive in the face of homophobic-related challenges is not new and dates back to the HIV epidemic when LGB people embraced each other as family and a source of care in the absence of ties to biological family. However, this community-centered approach to care was not reported by participants as a deficit, but was instead viewed a means through which joy could be found in late life. Similarly, other research on older LGB adults suggests that there are unique facets of queer subculture that prepare them well for the aging process. For example, the absence of gender norms that guide spousal-care decisions among heterosexuals may actually benefit same-sex couples; indeed, gays and lesbians often coordinate medical care together as they age, and they also spend more time discussing end-of-life care plans . AdditioThe article also offers greater insight into the distinctive meanings of “aging in place” among the LGB community. Heterosexuals similarly report a desire to age and die in one’s home with dignity, which is motivated by one’s desire to maintain independence . HoweverQueer aging also entails a uniquely interdependent approach to care as reflected in participants’ reported desires to “age in community”; that is, they wish to age in close proximity to similar others via LGBT-friendly retirement communities, gay neighborhoods, and cohousing. This interdependent approach to care departs from a tendency to want to preserve independence as long as possible, which is often found among heterosexuals (osexuals . Similarosexuals . Such anosexuals . AccordiParticipants also reported a desire to pursue assisted suicide should they no longer be able to provide care for themselves. The findings regarding “quality over quantity of life” likely reflect the fact that aging is constructed in U.S. society as negative and a period where “doom and gloom” narratives prevail . Thus, oThe findings also highlighted the importance of a life course perspective, especially potential generational differences . FinanciSimilarly, cohort differences in LGB people’s experiences with late adulthood may also emerge. Marriage equality likely leads to pressures for younger LGB people to assimilate into heterosexual culture, potentially diminishing the distinctiveness of queer subcultures . YoungerThe study has sampling limitations, necessitating that future research further investigate how social identity characteristics shape older LGB people’s experiences. Because the study omitted transgender people, it is vital that future researchers investigate whether they experience distinctive late-life challenges. Only a small handful of studies investigate transgender people’s views of aging, with studies suggesting that they are less likely to be prepared for aging-related challenges—due to a need to use most of their time to focus on day-to-day survival in light of unemployment and poverty. Moreover, older transgender people face higher rates of loneliness and depression, financial distress, and exposure to discrimination in medical settings . In addiThis article has broader implications for gerontological practice as it pertains to LGB people. It is important that staff in health care settings be educated on how to provide culturally competent care, use inclusive language, and the unique issues facing older LGBTQ patients . This ty


Human groups tend to be much larger than those of non-human primates. This is a puzzle. When ecological factors do not limit primate group size, the problem of coordination creates an upper threshold even when cooperation is guaranteed. This paper offers a model of group coordination towards behavioural synchrony to spell out the mechanics of group size limits, and thus shows why it is odd that humans live in large societies. The findings suggest that many of our species' evolved social behaviours and culturally maintained social technologies emerged as solutions to this problem. DespiThere have been many attempts to assess the ‘natural’ or ‘ancestral’ group size of humans, often based on forager cultures today, or the, dotted, archaeological record –7. HowevThe second difficulty is methodological, the core of which is the definition of a ‘human group’. Hunter–gatherers tend to self-organize into hierarchical macro-structures –13, whicYet, even given these difficulties of definitions, it is clear that the natural human group ,16, at tBaboon bands sometimes form large meta-populations, but these are more like herds than groups in the ‘ape group’ sense . AlthougSomewhat similarly, the number of bats roosting in the same cave can range from hundreds to tens of millions ,27. Yet,Pair-bonded parrots and corvids, too, often form multi-male-multi-female groups, which, in the combination of these two characteristics of social organization, are similar to human groups and dissimilar to non-human primates –31. HoweIn ungulate herds, the primary problem is the coordination of movement –35, and Compared with these non-primate examples, human groups tend to have qualitatively different tasks: doing something together, for a shared purpose, in a technology that requires complex social interaction and the maintenance of trust and cooperative stance. The full list of typical tasks that human foragers perform is dramatically different from ungulates, bats, parrots or corvids.Most human activities are performed in small cooperative subgroups. For instance, collecting vegetal foods, shellfish, eggs, insects, small fauna or honey could be done alone as far as the technology is concerned, but tends to be a small-group activity, presumably as a predator avoidance tactic ,41. In tThese technologies not only go beyond herding or flocking behaviour in the need to rely on each other but they also tend to be more complex. Pack hunters like dolphins ,44, wolvThe largest non-human groups are formed in times of inter-group violence, swelling up from smaller group size during peace time ,55, and Opposed to non-human animals, human populations regularly, and in all cultures, engage in complex group activities that require solving complicated coordination problems, and are not seen in any non-human animal ,60, but In other words, human collective action in small groups can be seen as similar to some group-living animals’, although typically more complex. However, unlike in humans, these non-human examples of complex collective action always run into a group size limit, even when larger groups would be clearly advantageous, like in the case of inter-group violence. At the same time, examples of large animal groups, like ungulate herds, schooling fish, and flocking birds, follow a simple logic of collective action: that of predator avoidance. And while more complex collective action can occur in bats, parrots and corvids that, at the same time, live in large mega-populations, the logic of these super-large groups is either predator avoidance, or parallel use of a resource, like a shelter, or prey swamping, and the complex collective action, like forming foraging parties, nest building, occurs in small groups only.natural groups. We know from other areas of human life that modernity can change our ancestral ‘setting’, for instance the majority of us gave up foraging for farming [Furthermore, in different technological environments, humans regularly form groups of millions and even billions of people. The median country size today is 6.7 million people, and the median size of the largest city in any one country is 2.1 million people . Arguabl farming ,68, equi farming ,70, and  farming –73.) ThuThis is a puzzle. How come that human ape groups are so large? And if they can be this large, how come that other apes' and non-ape primates’ groups are not as large? Much of the scientific literature about human social evolution has been concerned with the tricks and ruses that our species evolved and invented to allow large group size. But under these shelves of papers lies the assumption that forming super-large groups is something unnatural, something odd. If there was no limit, why would there be a need for a trick to break through it? To my knowledge, there is no paper in the literature that spells out this assumption by asking the question: why is it odd that we live in large societies?. 2n agents form a randomly connected graph of degree k, with adjacency matrix a = {ai,j}jI,, where ai,j = 1 if the agents i and j are connected to each other. These agents face a problem such that they must coordinate their action to be able to act as one. The coordination takes place on a unit circle, as if each task was finding a shared direction on a compass [Let  compass –77.The agents start with a randomly assigned initial value drawn from a uniform distribution on a compass .ϕ values. For each synchronization event, two connected agents are randomly picked, and their ϕ values set to the mid-point of their old ϕ valuesFor the group to reach behavioural synchrony, the agents go through a series of pair-wise meetings in which they synchronize their δ denote the average distance among the ϕs of all the group members.t is the average number of meetings an agent has, and the | | distance measure refers to the nearer side of the unit circle.  Notice that δ is an inverse measure of synchrony, i.e. group's coordination efficiency is high when δ is low, and vice versa.Let k > 2 and the graph is connected, the ϕ values converge and the δ goes to zero with t increasing . That is, as the number of meetings goes up, the group turns towards the same direction.Independent of network structure, as long as and the graph is circular, convergence happens. The only question is the speed.This pattern of convergence is not surprising. This is an instantiation of an established result in network science, often employed to describe innovation diffusion in social networks ,79: unleNotice that the speed of convergence is driven by the average number of edges per node . This is also not surprising: the more connected a network is, the faster the synchronization is, another established network science fact. This speed difference is important, because if the network describes a real-world human (or other species') cooperating group of individuals, then the amount of time that the group members can spend is likely to be limited by ecological, technological factors.τ, as a parameter external to the coordination problem  works on the level of the individuals, and thus that the agents decide their number of social connections for themselves. Let us assume that social connections come with synchronization benefits and costs of relationship maintenance that translate into a pay-offTo evolve the optimal degree, let us use an evolutionary algorithm the following way:n agents, assign random degree uniformly to each agent such that ik denotes the degree of node i, with one agent having k − 1, and one k + 1 connections. (This set-up ensures that the corresponding graph exists).Step 1: For a group of τ. Calculate the mean pay-off for each agent.Step 2: Run a large number of group coordination events, with a fixed limit of average number of meetings at k to the degree number of the best performing agent.Step 3: Given the pay-offs, set Repeat steps 1–3 for an evolutionary round.Using this selection algorithm, the degree evolves in line with the social costs of an edge . If contact maintenance costs are low, then the individuals are best off to have many social connections, and vice versa, when costs are high, the social network will be sparse.Thus, from the fact that the group needs to coordinate its action comes two opposing pressures. On one hand, the group's coordination efficiency increases when there are more connections among the agents . On the other hand, the agents will end up limiting the number of connections if these are costly .k is less than maximum.Notice that there are two kinds of costs in this model: one on the individual's level, and one on the group's level. The cost of an edge is suffered by the individual, and is not linked to the group's coordination problem. However, a loss of group-level coordination efficiency emerges if τ and β together determine the relationship between group size and synchronization efficiency  function is entirely determined by τ and k, with the latter entirely depending on β, and the equation τ, β and λ), and nothing else, determine the maximum group size. Thus, it is the ecological setting together with the nature of group coordination that set the maximum group size. Above this, a group cannot function in this model.Notice that as the . 3This paper used three parameters as a frame to collective action coordination: time limit, cost of maintaining a social connection, and minimum coordination efficiency threshold. The result showed that in a behavioural synchrony framing these three parameters together determine a maximum group size.There are well-documented human behaviours in which the need to reach behavioural synchrony efficiently limits group size. For instance, jazz jam sessions are limited to small musical band size –82.Four empirical questions follow: (i) is there a group size limit for non-human primates, (ii) if so, do human groups break out of this limit, (iii) if so, are there special evolved or cultural ‘solutions’ in place to facilitate going through such a threshold, and (iv) is there a possible ‘social technologies exchange’ with eusocial insects living in complex, very large groups?First, the group size distribution of non-human primates  is in line with the model's suggestion that such maximum group size exists: most primate species' group size is under 20, and among the few that have larger groups, none is above 100. Our closest relatives’, the other great apes', average group size ranges from nine (eastern gorilla), to 42–46 (chimpanzee and bonobo), with all the orangutan and gorilla species falling in the lower end of the range ,83,84.Second, ethnographic data are in line with the suggestion that the human group size is beyond a threshold that other primates did not cross.For instance, let us consider the case of small languages: the median speaker number of a language is under 1000 on all continents ,86. The In this highland region, crossing other groups’ territory is highly perilous, intergroup violence is ongoing.  The most likely explanation for the separation of the languages is that it is impossible to maintain military domination across several valleys at the same time. As an exception that supports the point, the Dani culture, which has approximately 600 000 speakers, occupies the only large flat area of Irian Jaya Highlands: the Baliem Valley.In the Papuan example, the median number of speakers per language, which is 643, probably corresponds not only to an ethnolinguistic meta-population, but also to a reasonable estimate of the number of people who live in a relatively small valley, relying on each other for protection against the enemies around. For this reason, 643 may be seen as a good estimate for the highest-level group size in the Highlands, whether they split into separate settlements or not. This is in line with the observation from a very early, 1961, population survey that while the average settlement size was 159–170 people, depending on measurement ,90, the Using the New Guinea example, the average human group size is at least four times as high as that of other great apes, possibly 15 times larger. And when comparing maximum group sizes, the difference is even starker. The largest non-human great ape group ever recorded was the Ngogo chimpanzee ‘community’ that ranged between 140 and 206 members . CompareThird, how is this large human group size possible? To what extent did our species' tricks in ‘social technologies’ evolve or were invented to solve the problem of the looming group size limit? Did language evolve as a third-party information processing tool to facilitate larger groups –95? Did Fourth, although the human ability to form large, complex groups is unique among vertebrates, eusocial insects tend to form hives or nests that often comprise tens of thousands of individuals. These perform a range of complex coordinating tasks like nest building, nest hunting, collective foraging –108, andAnswering these questions is essential for understanding how it could be possible to use social technologies that would facilitate building a cohesive group of 8 billion human apes, which is arguably essential for this species to tackle the substantial coordination problems it faces on a global scale.Note that this paper focuses on group size being limited only by coordination efficiency. This model assumes away the problem of cooperative stance, and dyadic cooperation is implied in the cost of maintaining the social network edges. Yet, there is an entire library on the origins of costly cooperation –120, and


Many men seek medical treatments complaining that their penises are too small (short) when in fact they are not (they are not cases of micropenis). The objective of the present study was to evaluate men’s satisfaction with their own bodies and sex life and the prevalence of erectile dysfunction, among men who were not seeking medical or psychological advice. Cross-sectional study in a private, philanthropic hospital in São Paulo, Brazil. In this study, 300 male blood donors aged between 40 and 60 years old answered a questionnaire, in privacy, about their sex life and their satisfaction with their own bodies. They were also screened for erectile dysfunction by means of the International Index of Erectile Function questionnaire. Seven men (2.3%) reported that they were dissatisfied with their penis size , and among these, one was found to have mild erectile dysfunction. However, none of them had sought medical attention. Among these seven, only two had normal body mass index; the other five were overweight (three) or obese (two). The prevalence of dissatisfaction with penis size was low. Among the seven dissatisfied men, only one had erectile dysfunction, of mild type, and all of them felt potent. Phalluses are often represented in ancient and modern pictures and sculptures in many regions of the world. Penis size is given much importance, especially by men, and it is commonly cited as an attribute of hegemonic masculinity.,In recent years, patients seeking treatments for what they call “small penis” have sought urologists more and more frequently.,,,,,,,,,However, most of the men (or parents bringing children) seeking help for “small penises” do not really present abnormal penis sizes.What would be the beliefs of men who have not sought medical advice for penis enlargement? We recently communicated the results from a cross-sectional study on the prevalence of erectile dysfunction in men who considered themselves healthy  and who were not seeking diagnoses or self-information on sexual behavior or function. That studyThe aims here were to investigate: 1) the prevalence of dissatisfaction with penis size, the whole body and sex life, among those men who were considered healthy (blood donors) and who were not seeking treatment; and 2) whether men dissatisfied with their penis size would also suffer from erectile dysfunction, as defined through the International Index of Erectile Function. The hypothesis was that there would be cases of erectile dysfunction among men who were dissatisfied with their penis size.In this cross-sectional study, male blood donors were contacted in the waiting room of a private, philanthropic hospital in São Paulo, Brazil, between January 2006 and July 2007. The hospital’s Ethics Committee approved the study and all participants signed informed consent forms. To be eligible, the blood donors had to be 40 to 60 years old, with at least four years of schooling . Being heterosexual and in a stable partnership for at least six months, irrespective of marital status , were also inclusion criteria. Those unable to understand or answer the questionnaires and men using medication that affects sexual functioning, such as diuretics, antidepressants and hypertension therapy, were excluded. After excluding some participants based on these criteria, the sample was made up of 300 subjects.Data on weight, height and blood pressure were compiled from the subjects’ blood donation medical records. The men completed self-applied questionnaires in a single sitting: an identification form (for sociodemographic information), a questionnaire on erectile function and psychiatric screening. The presence of erectile dysfunction was evaluated using the International Index of Erectile Function, which had previously been transculturally adapted to Brazilian Portuguese.The subjects answered the questionnaires voluntarily while waiting to donate blood , and without the help or the presence of the researchers. They had privacy to respond, and anonymity was guaranteed.The frequency of dissatisfaction among the men regarding their whole body, penis size, sex life and erectile dysfunction was registered, as were their beliefs about sex. The profiles of the dissatisfied men were analyzed. The analysis was descriptive, presenting the frequencies of each personal characteristic or positive response to questions. No statistical test was applied because of the small size of the subsample.2; 200).As already reported elsewhere,Seven men said that they were not satisfied with their penis size. Among these seven, only two had normal BMI, the other five were overweight (three) or obese (two). Three men were not satisfied with their bodies and they all felt “fat”: two were in fact obese and one was overweight. Only one of these dissatisfied men (their profiles are described below) had erectile dysfunction as defined through the International Index of Erectile Function, with a score of 21, indicating mild erectile dysfunction. He was obese and said the reason for being unhappy with his penis size was that he did not know what a normal size would be. All of them responded that they felt potent.Seven subjects  were dissatisfied with their penis size. Their profiles  are desc2) presented erectile dysfunction that was classified using the International Index of Erectile Function questionnaire as mild erectile dysfunction . This was the only man who reported having penile curvature, but he had never asked for medical advice about this. He felt uncomfortable with his body, because he was overweight. He was satisfied with the relationship with his partner, but had not felt sexually attracted to her for the last two years. In his opinion, his sexual desire was now “moderate”, and it had been like that for three years.Subject # 15: This obese man (BMI 33.56 kg/m2) thought that he was fat, with a waist that was too large. He desired a bigger penis. This man felt potent . He was satisfied with his relationship, and felt attracted to his partner. He said that he was comfortable talking about sex.Subject # 26: This overweight man (BMI 26.70 kg/m2). He was very satisfied with his partner, to whom he was attracted; he felt potent  and thought that his sexual desire was “high”. He was satisfied with his body, but he thought that his penis was “small”. He responded that he felt comfortable talking about sex.Subject # 102: This man had a normal weight for his height (BMI 23.66 kg/m2) was satisfied with his partner and felt attracted to her. He felt potent  and felt sexual desire. He was not satisfied with his body and said that he was “fat”. He considered that his penis was “small”. He did not feel ashamed talking about sex, but neither did he feel comfortable about it.Subject # 171: This obese man (BMI 32.36 kg/m2) was highly satisfied with his partner, to whom he felt attracted. He felt potent  and classified his sexual desire as “high”. He said that he felt “ok” talking about sex.Subject # 209: This slightly overweight man (BMI 25.77 kg/m2) was moderately satisfied with his relationship. The reason that he gave for this was that his family was feeling insecure about a possible transfer to another country, because their children had already moved out. He felt attracted to his partner, felt potent , but felt that his sexual desire had been “moderate” for the last two years. Nevertheless, he had not sought medical advice. He was satisfied with his body but not with his penis, which he thought was “small”. He did not feel ashamed talking about sex, nor was he comfortable.Subject # 227: This man with normal weight (BMI 22.75 kg/m2). He was satisfied with his body, but not with his “small” penis. He was highly satisfied with his relationship and he felt attracted to his partner. He felt potent  and his sexual desire was good. He felt “ok” talking about sex.Subject # 233: This man was slightly overweight  was ideal; 85% overestimated the normal penis size. However, 15% had no idea of what a normal penis size should be. None of the subjects had anatomical abnormalities or erectile dysfunction. The majority of them started to be concerned during childhood, when they felt their penises were shorter than those of their school colleagues, or during adolescence, when they began to watch erotic movies. A nomogram of the sample was constructed and none of the men was found to be below the average size. After being informed of this, 70% of the patients gave up the idea of having surgical treatment.Three years later, the Egyptian urologist ShamloulThe data presented here were collected as part of a larger study of ours.Therefore, our study did not measure penis size or make any physical evaluation: we only asked for men’s opinions about their own bodies. Thus, it was not possible to verify whether they had real reasons for concern or any detectable clinical/anatomical problems. Nor was it possible to psychologically evaluate whether these men were simply dissatisfied with an esthetic feature or whether they were really suffering from a “phobia”, i.e. a mental disorder characterized by an “imaginary defect” or an “obsession”.While simple esthetic problems  can be fixed successfully by means of esthetic surgery, penis enlargement is a complex operation with somewhat unpredictable results. The men described in this study, despite being dissatisfied with their penis sizes, had not sought medical or psychological help, nor had they informed themselves about what a normal penis size should be or obtained a solution for their problem. It would have been necessary to evaluate them individually to ascertain whether the problem was only mild esthetic discomfort , which is something that people can cope with over a long life, or whether it was something that led to distress.It would be premature to say that the men in this study needed treatment, but on the other hand, their profiles suggest that this finding might have been associated with general dissatisfaction with the whole body, and not only the penis. These men would probably have benefited from referral for psychological evaluation.,,,,,,Over the past year, several studies on men’s normal penis size were published, providing average length and circumference measurements.Another insight that can be obtained is that, as shown by other studies, because the idea of “normal penis size” varies according to the population, the cultural characteristics of the men should be taken into consideration. Brazilians might be more (or less) demanding about penis size than other populations, and only a larger study would be able to confirm whether this 2.3% prevalence of dissatisfaction would be representative of the national population. Phalloplasty would, in this context, be an individual solution for a cultural problem. Exposure to pornography should also be investigated, since it certainly gives many people nowadays a visual idea of penis size and function.As stated by Lever et al.,Because of the lack of standardization of clinical study reporting, descriptions of the complications may be lacking in many of the published articles. Ghanem et al.As shown by the Italian study,The possibility that complaints of small penis size might be associated with erectile dysfunction was not confirmed in the present study. Only one of the dissatisfied men had erectile dysfunction as defined through the International Index of Erectile Function, and he presented a score of 21, indicating mild erectile dysfunction. He was obese and said that the reason for being unhappy with his penis size was that he did not know what a normal size should be .All of the men interviewed responded that they felt potent, i.e. that their penis size was not interfering with erection. It is interesting to observe some paradoxical findings about their responses: firstly, although all of these seven men declared that they did not feel uncomfortable talking about sex, none had ever sought specialist advice about their dissatisfaction with their penis size. Two felt moderate sexual desire and moderate satisfaction in their relationships and one had no sexual attraction towards his partner at all. Nevertheless, none had sought medical or psychological counseling.Reassurance work can be performed based on discussion of the common myths about sex that are spread around the population and which may contribute towards individuals’ dissatisfaction with their body and sex life. Zilbergeld, in his book “The new male sexuality”,,Thus, most men really do not have a realistic basis for comparison, and this was shown by both the Italian and the Egyptian study.What healthcare professionals should be aware of is that psychological counseling is helpful in restoring the quality of the sexual life of these dissatisfied men, and that a psychological clinical evaluation can also rule out other problems that may have been hidden, such as body dysmorphic disorder. These may be physically normal men with psychological complaints that may require evaluation, and these findings should be disseminated among the medical and psychotherapy communities, so that healthcare professionals can challenge patients’ beliefs about the association between penis size and masculinity.The use of blood donors as the subjects for the present study was considered to be an alternative to using urology clinic patients, healthcare service users or volunteers, who may be more prone to suffering from erectile dysfunction and other health problems than the general population (selection bias resulting from their interest in seeking treatment). These male blood donors were at least theoretically healthy and, most importantly, they were not seeking treatment for penis enlargement or sexual problems. Nonetheless, some of them (2.3%) were dissatisfied with their penis size.Some studies have actually measured penis size among men in different populations. Data is already available in Brazil for comparison. A recent Brazilian study identified penis length among boys aged 0 to 18 years. The study was undertaken among 2010 subjects and found that the real length of the flaccid penis  was a consistent measurement, and 145 mm (with a standard deviation of 16 mm) was the average found for 18-year-old boys.Given the intimate nature of some of the questions involved in such studies, it is possible that subjects feel more comfortable providing answers on their own rather than directly to a researcher. This is the reason why our choice of a self-applied research instruments may have brought reliable results about penis size perception.On the other hand, the present study was developed in the form of a cross-sectional study, which does not allow causal inferences between the outcomes studied and the characteristics of the subjects in the study . One limitation of this study was the age of the men who were evaluated (40 to 60 years old); perhaps a younger population would have had a higher rate of dissatisfaction with their penis size. Nevertheless, this study provides some evidence that dissatisfaction with penis size may be an overlooked problem with a possibly unnoticed disorder.1. The prevalence of dissatisfaction with penis size among healthy middle-aged men was low. 2. Erectile dysfunction was not common among the men who were dissatisfied with their penis size. 3. The majority of the men who were dissatisfied with their penis size felt potent and sexually attracted to their partners, but they were overweight or obese, and this was a matter of concern to them.


Wakakosha, “You are Worth it”).Self-stigma—negative self-judgements or core beliefs—can result in feelings of shame, worthlessness and self-blame, and impacts social interaction, mental health and health service utilization among people living with HIV (PLHIV). Few interventions target self-stigma among PLHIV and, to our knowledge, none until now for adolescents and young people LHIV (AYPLHIV) in sub-Saharan Africa. We present qualitative findings on the perceived impact of a self-stigma intervention (Wakakosha intervention adopted inquiry-based stress reduction (IBSR) at its core—a unique way of identifying and questioning deeply rooted self-stigma, combined with mindfulness, meditation and creativity. The intervention consisted of 16 × 3 hour group sessions. Supporting the intervention was a 156-page activity journal. We utilized a qualitative enquiry to explore the perceived impact of the intervention at various time points between November 2021 and November 2022, with 62 participants . Discussions explored experiences of being involved in the intervention and any reports on changes in relation to self-stigma and shame. Additionally, we reviewed intervention documentation and creative elements. A thematic analysis guided generation of themes across all data sources.The Both intervention participants and coaches described the transformative effect of the intervention, detailing their experiences before and after. Main themes that emerged were positive changes around: self-confidence, self-agency, sense of purpose/meaning, body positivity, improved communication and personal/family relationships and, forgiveness. The intervention also transferred a set of practical skills on self-inquiry, mindfulness, meditation and creativity that continued to be used in participants’ daily lives.Wakakosha intervention, using IBSR supported by music, creativity, writing and mindfulness techniques, showed potential for reducing self-stigma and improving self-worth among AYPLHIV. It also transferred practical skills to intervention participants and peer coaches, building their capacity to support others and deal with life challenges beyond HIV. The next phase is to continue supporting the young people to ensure fidelity as the peer coaches deliver the intervention to others. Study results indicate that culturally and practically, interventions to reduce self-stigma and/or improve self-worth operate at various levels and need to be designed and assessed at each level.The  More than four decades into the global HIV pandemic, stigma remains a major barrier to HIV treatment, management and care . GoffmanSelf-stigma can result in non-adherence to HIV medication, lower quality of life and poor mental health , 11. A sWhile most stigma initiatives focus on averting discrimination  , the pheSelf-stigma occurs at the individual level, but also influences interpersonal relationships, community participation and engagement and, ability to access rights and health services . We prevWith reference to Zimbabwe, previous research has shown that AYPLHIV are particularly affected by stigma and self-stigma , 16, 23.p = 0.03)  . Zvandir = 0.03) .Evaluations have illustrated peer-support groups’ potential in significantly transforming AYPLHIV’s perception of HIV as a debilitating infection which they are experiencing in isolation, to a manageable condition , 28, 29.We sought to adapt and optimize an innovation we previously piloted among adults living with HIV in Zimbabwe—inquiry-based stress reduction (IBSR): the work of Byron Katie . IBSR isWakakosha intervention aimed to equip AYPLHIV (aged 18–24 years) in the use of IBSR/self-inquiry to manage stressful beliefs, reduce self-stigma and grow their sense of self-worth and wellbeing. Following formative research in 2021  to start with several universal stressful thoughts about being HIV positive and from there, to work systematically through more acute self-stigmatizing core beliefs at a deeper level each week. Introductory sessions on thinking, identifying and feeling emotions were also provided before progressing to the deeper issues in the curriculum. During the process, participants were encouraged to identify, and inquire about, their stressful thoughts regarding shame, HIV status, disclosure to others, sexuality, judgements of self/others, the body, illness and death. Overall, the intervention aimed to improve management of specific emotional and psychological symptoms . The intervention consisted of 16 × 3 hour group sessions which included individual and pair work , this time delivered mainly by peer coaches (supported by adult coaches). Each day of the training and/or intervention was evaluated, and feedback used real-time to adapt and ensure the curriculum was meeting the young people where they were. Towards the end, participants produced a song and recorded a music video which showed their experiences of the program and what happens when self-stigma is addressed. They also produced a podcast series through which they shared their own letters and poems about the body and forgiveness (available: https://www.beyondstigma.org/videos).Thirty Zvandiri Community Adolescent Treatment Supporters (CATS) were initially recruited in 2021 to receive the intervention delivered by trained adult coaches . CATS are 18–24 years-olds LHIV, trained, mentored and supported to deliver structured support groups, counselling and tailored community-based adherence support to their peers , 28. FroWakakosha intervention at various time points. Firstly, in November 2021, a focus group discussion (FGD) was held with 12 of the 30 CATS who were the first to receive the intervention. Another 12 CATS took part in in-depth interviews (IDIs) between November 2021 and February 2022. Additionally, 12 of the 15 CATS recently trained as peer coaches took part in a FGD in March 2022. In addition, 24 of the 30 CATS recently trained by peer coaches took part in two separate FGDs in November 2022. We also conducted key informant interviews (KIIs) with 2 of the 4 adult coaches who had facilitated the intervention sessions  (see sample interview questions in All discussions were led by two experienced Zimbabwean researchers (WM and ON) in private spaces and lasted approximately 30 min  and 1.5 h (FGD). All discussions were conducted in Shona, the participants’ language. With the participants’ permission, the discussions were audio-recorded. The recorded interviews were transcribed and translated verbatim into English. Interviewers (WM and ON) reviewed all transcripts to confirm their accuracy. A summary was written for each individual interview or FGD.n = 6) were thematically coded by two researchers (WM and ON), using deductive and inductive approaches by creating a coding framework based on the topic guides and adding codes iteratively (credibility (ensuring researchers’ representation of themes fit with participants’ views) and confirmability (ensuring interpretations were clearly derived from the data)  . Researcdability .Any additional codes identified from this first set of transcripts were added to the coding framework. Transcripts were entered into NVivo 14  and fully coded using the modified coding framework; care was taken to identify any additional emerging codes. Codes were grouped and emerging themes were identified and supported with verbatim quotes. A workshop was held with three peer coaches  and two adult coaches (SV and MC) to review research findings and contribute to manuscript writing.Between November 2021 and November 2022, sixty young people LHIV, aged 18–24 years took part in the research. Of these, 30 (50%) were female. We also held discussions with two of the four female adult coaches see .Wakakosha intervention, detailing their experiences before and after. The main themes that emerged were the existence of previous self-stigmatization and the move to positive changes around: self-confidence and self-agency, sense of purpose and meaning in life, body positivity, improved communication and personal/family relationships, self-forgiveness and forgiveness of others. These themes are described in detail below.Overall, both intervention participants and coaches described the transformative effect of the Wakakosha. One participant noted that there were “…certain things that might happen. Simply because you are HIV positive you will begin to personalize issues… ‘So this person did not see me when I was passing by…Has she heard something about me?’ You might be assuming that someone has ignored you, yet this is all in your mind…” . Participants also described instances of negative self-judgement. “…Telling yourself that you cannot do this because of your (HIV) status” .Participants described how they experienced self-stigma, including negative self-judgements, prior to enrolling onto When I was home and we had visitors, I would shut myself in a room because I am HIV positive…I was worried that visitors would see me and guess my status. I was worried that family members would disclose my status to others. So, you are always alone in your room, and this causes so much stress because you are always assuming several issues” . One participant described how similar distressing experiences triggered perpetual suicidal thoughts. “I was only thinking about death…It was better for me to die as there was no reason for me to continue living. My relationships were difficult and there were also challenges at home because of my (HIV) status” . Prior to the intervention, participants not only agreed with stereotypes or negative perceptions about themselves but applied them too, including the belief that they could not amount to anything.Participants described effects of these self-stigmatization experiences including self-isolation and depression. “I encouraged her, and she enrolled for a teacher training course” . Another participant reported pursuing a career as a nurse aide. Some participants reported renewed self-agency. A participant who had inherited a piece of land but was not using it productively due to self-stigma-induced loss of self-agency reclaimed it and started farming, remarking that, “I would tell myself that there was no way I could farm that whole piece of land…If I had not attended Wakakosha I would have surrendered the land to someone else” .Intervention participants described gaining various skills including self-confidence. This often prompted them to pursue previously “impossible” goals such as enrolling for academic and professional courses. “After the training I learnt that there is nothing I cannot do, and I can do it” . More so, the intervention inspired a sense of self-worth and purpose in the participants, with some rediscovering their entrepreneurial passions. Another participant labelled themselves “a jack of all trades” attesting to a renewed entrepreneurial drive and passion for new vocations, stating that, “I am now involved in five things…welding, plumbing, art, building and fashion” .After the intervention, participants affirmed a new sense of purpose in their lives as reflected by one who noted that, “I used to hate my body, and I would say, “I do not want my body because I am tiny. I do not want my skin because it is too dark” . Yet another participant narrated, “I would ask myself why I was not gaining weight…my body was too thin. When I looked at other girls with bigger body structures, I would ask myself why I could not also get there” . Participants further acknowledged different ways in which they mistreated their bodies, with one admitting to their body that they, “hurt you (body) terribly by not caring well and starving you because of my self-stigma…” (Dear Me Podcast #4), while others engaged in alcohol and drug abuse as well as deliberate self-poisoning in a bid to kill themselves .Because of self-stigma, participants, especially female ones, developed negative attitudes towards their bodies as evidenced by reports of having previously been ashamed of, and neglecting, their own bodies. A participant remarked that, Wakakosha. Noteworthy was the body positivity message that the intervention inculcated in participants, motivating them to reevaluate their beliefs and attitudes towards their bodies and embracing body positive routines. One participant remarked that, “It was only after Wakakosha when I realized that I should be proud of my body because my face has not been reacting to the drugs that I am taking” . More so, a recurring message in the Dear Me Podcasts is that of participants committing to taking better care of their bodies through eating healthy, quitting alcohol and drug abuse as well as improved hygiene .Such thoughts, however, changed upon completing I would tell myself that “I am HIV positive; I cannot date someone who is HIV negative” . Even when they were now in relationships, participants would worry about family size and “curtailed” longevity. “I was stressed. When I gave birth, my sister-in-law said ‘You should not have another child because you are going to die soon. Who will take care of your children?’ So, I had told myself that it is fine to just have one child. I held on to those words…” .Participants also reported improved communication and personal relationships. As participants were relatively young (18–24 years), forming relationships was one of their key considerations. Nearly all described previously struggling to come to terms with their emerging sexuality in the context of a life threatening, sexually transmissible infection. now (after the intervention) I have realized that I am now more humane, I am no longer exchanging (harsh) words and I now respect him…” Another participant was elated with how his love life had improved, stating that, “My love life is now great. Yesterday was a wow for me. We were coming from church, and she invited me for dinner. It was excellent. My love life is now great” .Post intervention, participants reported improved personal and family relationships. Most participants reported previously being bitter and angry towards their parents, relatives, and other members of the community. One participant reported that after the intervention relations thawed between him and his father, admitting that “…Even to my dad, I used to believe he was stigmatizing me when I was young…he did not visit me. So, I just wrote a letter to both asking for forgiveness. I learnt about forgiveness because I was very bitter towards my parents about being the only child who was born with HIV in my family” . Through the intervention’s transformative effect, participants also learnt self-forgiveness as evidenced in the powerful messages of forgiveness in the Dear Me Podcast series. Participants also asked for forgiveness for having put their bodies on the line by starving themselves and abusing alcohol  while others forgave themselves for ignorantly indulging in risky sexual escapades .Many participants reported positive changes in self-forgiveness and in forgiveness of parents for passing on HIV. Most were bitter towards their parents but through the intervention, they were able to forgive and erase the negative thoughts, “Wakakosha intervention had helped him find closure. “So, I wrote a letter (as part of intervention activities) to both of them (deceased parents) asking for forgiveness…” . He went on to describe what he did next. “One weekend I travelled to the rural areas, bought flowers, and went to their graves and ‘said’ to them ‘I am very sorry for not forgiving you all along…’ I then placed the flowers on their grave” . Another male participant stated, “I wrote a letter to my mother asking for forgiveness. I was angry due to my status, saying ‘I am HIV positive because you were careless. You were careless with your life, and you gave birth to me fully aware of your status.’ So, I wrote the letter asking for forgiveness because I was ignorant” .A male participant described how the …She was blaming her uncle (father’s young brother) for ill-treating her after her father’s death. But after doing the session, she realized that this uncle did all he could to provide for her and her siblings. For example, he paid their school fees. She wrote an “amendment letter.” She was now saying that she has actually realized that her uncle was not a bad person. He was actually a good person for taking care of her. As an uncle, he was not obliged to look after her when her parents passed on. So she realized that she had to thank him” .Some letters were addressed to surviving relatives. “N’anga haizvirapi”  , an expression which underscores that CATS need support too. “Also, it helps us the CATS. Yes, we might be trained but, in some instances, you will be focused on other people. But with Wakakosha you are also focusing on yourself” .Both intervention participants and coaches (facilitators) described an overwhelming transformative effect of the intervention. CATS described for example, how they often spend time and effort offering peers support around adherence and overall wellbeing support, and rarely get the opportunity to introspect. Despite their mentorship, training, and support, they reported feeling unable to address personal challenges including self-stigma. One CATS summed up this shortcoming through a local proverb “We were taught that if there are challenges, we should not see these as permanent. We should have positive and not negative thoughts only. For example, when faced with a situation, we could only view it from the negative side, without looking at the positive side. Through this program (Wakakosha) I was taught to look at both sides and then think about how I can overcome the problems that I am facing” . As with other participants, he found this problem-solving skill quite empowering.Participants described in detail the new skills they had acquired. “I have skills that I am using on other people. There is one called box breathing. We would do this box breath whenever we were starting sessions. You would close your eyes and breath in and out… breath in and out. I normally use this when I am with a client who is disturbed and is facing some challenges. Maybe he is not calm…I can also ask them to give me their emotions from 1–10. By so doing, you will realize that I am feeling this emotion because of this and that. We will then start the counselling session .CATS were also equipped with vital skills they now use to help their peers. …In the ‘journal,’ there were some ‘exercises,’ and these were part of homework. You would ask yourself through the sheets the emotions that you were going through on that particular day. You would then circle. From there, you would then start doing an inquiry using that yellow card that contained the four questions and the turnaround prompts. And then stressful thoughts that caused you to be in that emotional state will begin to emerge. And then at the end of the day you will be in a different emotion” .Commenting on the activity journal, a participant stated “So, the skills that I am using on other people include inquiry and the yellow card. Out there, there are peers who might be having stressful thoughts. Sometimes when I contact a client, I will end up using that yellow card” . Another participant highlighted how components of the intervention can be used beyond self-stigma situations, noting that, “…When I go home and I start doing this with my aunt (55 years old), asking her to turn around her thoughts. Holding the yellow card and asking her about her thoughts on that issue. I will then ask her to do the turnaround thoughts… turn around to yourself. At the end of the day, she will start laughing asking if these were the activities we were doing, and I would say ‘Yes’” . Overall, participants felt the skills they learned could be applied beyond self-stigma into their everyday lives, in particular the ability to solve problems.The acquired skill sets were not only helpful to intervention participants but also others. “The singing helped us easily share our feelings whether sad, happy or angry”  (creativity component of this intervention to be reported separately).Lastly, participants reported how creativity  helped them engage in challenging topics on self-stigma, thus promoting awareness and healing. “…Going forward, we will prefer face to face mentoring. There are instances when things are said, and you have to express your emotions…If it is online, no one can see what is going on. If you are discussing face to face, you can express your emotions and then you receive counselling” . A local adult coach weighed in, “Especially when we were still doing this from home (online), it was worse. It was okay when we were coming to Zvandiri because they have a strong network connection. But from home, you could see the young people complaining that there is no power and this affects network connectivity. Therefore, I did not like the online program at all, especially during the first days when everything was to be done online” . Implementing an online intervention within a context characterized by erratic power supply, limited internet connectivity and exorbitant data charges involves “scaling a mountain.”As already noted during the description of intervention delivery, due to COVID-19, some sessions had to be delivered online, which had its own challenges. Participants articulated some of the challenges. “I would like to go back to (activity) journals. Those are for us participants who are attending the meetings. However, there is over emphasis on HIV. Yes, it’s good but I might be staying at a home where relatives and friends come. Maybe I have not yet disclosed to them. Through this CATS program, we have disclosed, and we are now used to this. But some people might be affected when they are going around with that ‘book, and someone opens the ‘book,’ they will see text which reads, ‘Because of HIV….’ If only they could find other words to talk about HIV in a way other people will not know HIV is being discussed” . These concerns should be taken into consideration going forward.Some recommendations centered around ensuring intervention materials taken home do not result in inadvertent HIV status disclosure. “Wakakosha intervention effected positive changes on many aspects of self-stigma including self-judgements, self-worth, sense of purpose, self-agency in career and education, body image, self-forgiveness and forgiveness of others and improved communication with family and significant others. It also transferred a set of practical skills on self-inquiry, mindfulness, meditation and creativity that continued to be used in participants’ daily lives. We previously noted how interventions to support PLHIV in dealing with self-stigma, particularly at the level of core beliefs, are lacking . For an individual in Zimbabwe, as in most of sub-Saharan Africa, self-acceptance is bound up with acceptance within one’s community. Hence, for the AYPLHIV, it was difficult for them to separate themselves from the diminished status of their parents due to HIV infection, increasing the potency of the shame and self-stigmatizing beliefs they had about themselves and their parents. These difficulties of separating the self from others also strengthens the value of community and opinions of others regarding morality and HIV acquisition, which in turn fuels shame, self-stigma and the acceptance of social stigma and discrimination as well-deserved punishment for sexual deviance . The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.