N = 2418), we identified eight dominant pathways of employment, marriage, and parenthood among young women and found that educational attainment and family values are strong predictors of these work–family pathways. We also found that the timing and sequencing of work–family pathways appears to be associated with later health outcomes. In particular, unemployed women who are not married and do not have children seem to be vulnerable to health problems, compared to those with other pathways. We discuss the implications of our findings regarding the occurrence of work and/or family transitions, as well as their timing and sequencing for women’s health in later life.The aim of this study is two-fold: to discern patterns in pathways of work and family transitions among young women (aged 24–39 years) whose decisions and behaviors toward labor force participation, marriage, and parenthood are considerably shaped by social constraints and gender norms; and to examine whether and to what extent work and family pathways are associated with later health. Using data from a longitudinal survey based on a large sample of adult women in Korea ( Over recent decades, women’s labor force participation has continued to increase in many industrialized countries, while marriage and fertility rates have steadily declined . These cEntering the workforce and forming a family through marriage and/or parenthood are critical life transitions that influence an individual’s health and well-being in various ways. Not surprisingly, ample research has examined health consequences of these transitions among individuals, and the overall patterns of how employment, marital status, and parenthood are associated with health are relatively well known ,7,8,9,10Individuals’ decisions to enter and/or exit the labor force are often motivated by changes in their family status and circumstances. Of course, decisions to marry or divorce are also directly or indirectly induced by finance . Additionally, although non-marital births and childless married couples have been on the rise in recent decades, most children are born to married women, rather than unmarried women, and once married, people are more likely to have children, instead of staying childless. Moreover, while younger generations tend to have fewer children than previous generations, modern parenting has become more expensive and time-consuming . CombineThis study focused on young women in Korea. Women’s health is an important public health concern in many countries, including Korea. Often expressed as “gender paradox” , women The primary purpose of this study is two-fold. First, we attempted to discern patterns in the pathways of work and family transition among women. To do this, we employed latent class analysis (LCA) to identify the major pathways that young women take for work and family. Second, once we identify the pathways, we examine whether and how women experience their health outcomes associated with these pathways from a life course perspective. To do this, we used a series of regression models with data from a longitudinal survey of a large sample of adult women in South Korea (hereafter Korea). Young adulthood in contemporary society is typically characterized by several critical life transitions, such as completion of education, entering the labor force, having their own place to live, getting married, and having children. These transitions often entail additional social roles and responsibilities, which may influence other transitions and affect one’s life in various directions. According to the life course perspective, life pathways reflect patterns in the timing and sequencing of life transitions and their inter-connected social roles over the life course ,17, and In general, the cultural context provides normative expectations and guidelines for schooling, labor force participation, and how and when family roles should be fulfilled and combined with other social roles . In the Importantly, the combinations of multiple roles and timing and sequencing of work–family transitions may be influenced by education levels, available resources, and attitudes among women . Women wThere is robust evidence that employment has beneficial effects on the health of unmarried women e.g., ,20). In . In 20])Regarding women’s transitions to marriage and parenthood, ample studies have revealed several ways that it may affect the health of women. Overall, marriage is beneficial to women’s health, but parenthood is probably not ,7,8,9,10Similar to marriage, becoming a parent is a primary way of achieving an adult marker and fulfilling an expected adult role in many societies, where social norms about having children exist, and children may be an important source of enriching social ties and parents’ self-concepts and purposes of life ,10. HoweEducation is a strong predictor of work–family transition. For example, compared to non-college-educated women, those with college education or more tend to enter the labor force with a “good” job, and get married at later ages and stay in the marriage ,31. HoweIt is not uncommon for working women to put a stop to their careers or change their work from a full-time to a part-time job when they have minor children, either temporarily or permanently, because work may not be compatible with raising children. However, college educated women with a “good” job may have more advantages in reducing/avoiding role conflicts when adding the role of mother to their existing worker roles, as the good jobs may offer more resources that they can utilize. Conversely, less educated women with a “bad” job may encounter higher levels of role conflict than those with a “good” job, and they may not be able to afford to continue to work while caring for children . As a panel survey, the first two waves were conducted in 2007 and 2008; however, from the third wave onwards, the survey was conducted every other year, with the seventh survey in 2018 being the most currently available. We used all seven waves of the survey to investigate women’s family formation pathways and their associations with the consequences. One important advantage of the KLoWF is that it offers a wide range of information on childhood experiences, education, employment, women’s family life , attitudes toward family and gender roles, and health over time based on a large sample of adult women in Korea.Data for this study were obtained from the Korean Longitudinal Survey of Women and Family (KLoWF). Based on the 2005 Population and Housing Census, the KLoWF collected information from all women aged 19–64 years who lived in 9068 sample households across the country starting in 2007  to minimize potential endogeneity . We also excluded respondents who had missing information on self-rated health in the seventh wave (excluding 1702 respondents), generating 2418 respondents for the current analysis (352 unmarried and 2066 married in the first wave). Through the selection process, our analytic sample of young women was likely to be more educated and healthier than the general population of women of the same age on average. We discuss how this may affect our results later in this study.We relied on three variables from Waves 1 to 6 to explore the types of family pathways: employment status, marital status, and whether they lived with a minor child. For employment, we coded 1 if the respondents worked for pay (either full-time or part-time) in each wave and 0 otherwise. If the respondents were married in a given wave, they were coded 1 for that wave and 0 otherwise. To determine co-residence with minor children (less than 18 years of age), we used information on resident biological children drawn from the respondents’ household rosters and examined whether the respondents lived with at least one minor child. If they lived with at least one minor child within the same household, we coded them as 1 for that wave, and 0 otherwise. “Living with a minor child” is not the same as parental status; however, we believe this variable captures women’s role conflict between work and family more efficiently, likely influencing subsequent decisions on work and family transitions over the life course.To measure family resources, we used three variables from Wave 1: parental education, childhood economic status, and family structure while growing up. For parents’ education, we used a higher level of education for fathers and mothers. Parents’ education had three categories: middle school or below (coded as 1), high school (coded as 2), and college or above (coded as 3). Childhood economic status was measured using the question, “What was your family’s financial situation around the age of 15 years?” Based on the answers to this question, we divided the respondents into three groups: financially difficult (coded as 1), average (coded as 2), and affluent (coded as 3). Family structure was determined using the question, “Did you live with your parents around the age of 15 years?” If respondents answered that they lived with both parents, they were coded as 1, and 0 otherwise.Value orientations measured two dimensions: marriage and gender role. Four statements were used for each dimension. For marriage-related values and attitudes, we used the degree of agreement with the following statements: “everyone must get married,” “marriage should be with someone from a similar family background,” “it is better to get married early,” and “it is good to have children early if you are married.” A four-point Likert scale was used to measure respondents’ attitudes (strongly agree to strongly disagree). We reversed this original coding if necessary, so that higher values represented more conservative attitudes toward marriage. Attitudes toward gender roles were measured based on the following four statements: “ideally, men should have a job and women should take care of the household,” “housewives also have to go to work so that marital relations are equal,” “if housewives with preschool children work, it will have a negative impact on their children’s education,” and “the house couples live in must be under joint-ownership.” Higher values indicate more conservative attitudes toward gender roles. The educational level of respondents was categorized into three categories: high school or below (coded as 1), two-year college degree (coded as 2), and four-year college or above (coded as 3).Health was measured using respondents’ self-rated health in Wave 7. Self-rated health was assessed with one question: “In general, how is your health?” . In addition to the health at Wave 7, we also controlled for respondents’ health condition at the baseline measured at Wave 1. For both health measures, we reversed the original coding so that higher values indicated a better health status. Two variables were included as controls. First, we considered the health behavior variable, which was measured based on the question, “In the past week, have you been doing strenuous physical activity for more than 10 min or more than usual? If yes, please tell us how many days have passed in the past week.” Based on the responses to this question, regular exercise was recoded into a variable with four categories: no exercise (coded as 1), 1–2 days (coded as 2), 3–4 days (coded as 3), and more than 4 days (coded as 4). Age at Wave 1 was also considered.We proceeded with our data analysis in four broad stages . In the First, we used LCA to identify the differentiated types of pathways for our analysis. Work–family pathways are not well captured in a quantitative analysis because of several possible combined transitions between employment, marriage, and parenthood that have occurred at different times . HoweverTo determine the optimal number of latent classes, we considered both goodness-of-fit statistics  and theoAfter identifying eight work–family pathways (four pathways for married and unmarried women), we employed a series of multinomial logistic regression models to examine the predictor factors of the pathways, including family resources  and value orientations . In addition, we estimated OLS regression models to examine the association of the pathways with self-rated health, with various confounders  controlled for.Based on the results from the four-latent-class models, Next, we identify four classes of married women. As shown in To estimate the socioeconomic profiles of women and orientations toward marriage and parenthood across the eight classes identified earlier, we used multinomial logistic regression analyses. We conducted seven analyses for each class by comparing them with some work and no marriage/no children classes. As seen in Considering the rapid changes in family formation and rigid gender-role norms in Korea, this study was designed to describe various pathways of work and family among young women and to examine whether and how diverse pathways are associated with women’s health in later life. We summarize our findings in three ways. First, by employing an LCA, we identified eight distinctive pathways of work and family transitions. Specifically, working women without family formation were most likely to be observed among unmarried women in Wave 1, while about four out of ten married women in Wave 1 were stay-at-home mothers. These two dominant pathways reflect that many working women tend to stay unmarried and childless and that many married women stay out of the labor force while they raise children. These pathways imply that most women in Korea face high levels of role conflict between work and family domains, where many workplaces are not family friendly and women carry much of domestic labor and care work for children and older parents at home. The labor market in Korea is highly competitive and precarious , and thuSecond, the pathways were affected by several factors, including individual-level resources, attitudes toward marriage, and gender roles. For example, educational attainment is a strong predictor of pathways: those with a college degree tend to stay active in the labor force, and when it comes to family behaviors, they are more likely to marry at later ages or remain unmarried. Those without a college degree are more likely to marry early, have children soon after, and tend to experience interrupts at employment. We also observe that those with strong family oriented values are more commonly found among mothers (regardless of whether they work for pay).Lastly, the pathways are also associated with later health outcomes: particularly, women who are not married, do not have children, and are not active in the labor force report poorer health. Consistent with previous work , we did This study has several limitations. First, as indicated earlier, using a large sample of young women (aged 25–39 years), we selected those who did not have children outside of marriage and excluded some disadvantaged groups of women. Thus, we would like to call for caution when applying for young women in general, as our findings based on less disadvantaged women in this study are likely to serve as more conservative estimates, which underestimate existing health disparities across pathways. Second, given that we followed young women for their pathways over a 12-year span of time, we are aware that this period might not be sufficient to follow the entire work–family transition period during young adulthood. While indirectly, we attempted to cover the transitions as much as possible by looking at the respondents separately by marital status in Wave 1 . However, we cannot completely rule out possible variations in the work–family pathway trajectories between and within these subgroups of our sample, which we were unable to capture. Third, as another data limitation, this study explored only women’s pathways of work and family formation since data on men were not available. Although the life course trajectories of men and women have become similar owing to reduced gender inequality in work and family domains, looking at the transitions to adulthood for both men and women and their health implications are important for understanding young adults’ lives. Finally, this study examined the health consequences of the pathways using self-reported health. The pathways of work and family transitions might be differently associated with other health outcomes, such as psychological and emotional well-being. We suggest that future studies contribute to this line of research by addressing these issues when feasible.This study highlights that the timing and sequencing of work–family transitions have important health implications for young women in Korea. The timing and sequencing of life transitions are largely shaped by social institutions and cultural norms. Although the overall patterns in the timings and sequencing of work–family transitions have shifted and diversified in recent decades, our findings clearly suggest three messages. First, some types of pathways are more ideal than other types, at least for health. Given the higher levels of health observed among the women who made work and/or family transitions , compared to women who did not make any of the work–family transitions, young women seem to receive health benefits from both work and family. Second, when women perform roles in work and family domains, available resources from one domain may either reduce some role conflicts between the two domains or even facilitate role performance in the other domain. Lastly, and clearly not the least, our findings regarding the women who did not make all three transitions  imply that the current Korean society may expect young women to either participate in the labor force or form a family, if not both. However, the fact that many gender-inegalitarian and family-unfriendly work environments, combined with the increasing proportion of unmarried women, should be stressed as an important concern for women’s health and well-being in later life. For example, the Korean government should continue to increase gender diversity both in public and private sectors, especially at higher levels, as Korea is ranked at the bottom among the OECD countries, in terms of percentages of women in parliament and managers/directors. Also, the government should find ways to incentivize workplaces where work–family policies are well utilized. We urge that pursuing gender equity at workplaces may be the first step in promoting– the family transitions among young adults, which would improve the health of women (as well as men) in the long-term.


Despite the growing number of older people who live alone and in poverty, the intersection of these two social risk factors and the impacts on older adults’ health and well-being have not been widely examined. This qualitative study explores the challenges and strengths of 47 older people who live alone and in poverty in Hong Kong. Thematic analysis was used to identify eight themes related to challenges: (i) social isolation and loneliness, (ii) self-esteem and self-efficacy, (iii) declining mobility, health and activity levels, (iv) high medical expenses, (v) age discrimination and long wait times for medical health services, (vi) age discrimination, retirement, and wanting part-time employment, (vii) not enough gender-specific social participation activities, and (viii) housing insecurity. Four themes related to strengths were identified: (i) An “I have enough” mindset, (ii) strong formal social support, (iii) contributing to the community and others, and (v) “Most of us like to be alone.” Successfully addressing poverty in old age and tackling the challenges associated with living alone will require focusing on and activating not only external and systemic resources but also the intrinsic capacities and strengths of older adults themselves. Five discussion points are raised addressing the implications for future gerontological research and practice. The number of older people living alone is rising, in Hong Kong , and elsIn tandem with the growing number of older people living alone is the number of older people living in poverty, which is also rising, not only in Hong Kong but globally. Despite enhanced overall living standards and wealth in many developed economies, old age poverty persists. For instance, the latest rates of old age poverty in Japan, the United States, Australia, and Korea, were 19.6%, 19.6%, 23.2%, and 43.8%, respectively, while those countries’ GDPs per capita during the same time were relatively high . PovertyHong Kong has a persistent and growing problem of old age poverty. From 2010 to 2017, Hong Kong experienced, on average, an annual GDP per capita growth rate of 2.09% . In contOld age poverty has adverse consequences from the micro level to the macro level. Specifically, it has been associated with various negative physical and mental health outcomes for individuals ,25 and rLiving alone and in poverty are associated with negative health and well-being outcomes for older adults ,14,24,25Although older adults who live alone and in poverty certainly face various systemic disadvantages, they also have intrinsic strengths that have been largely unexamined but are important to identify and to utilize in the development of practices and policy interventions that support their health and well-being. For instance, Kok et al.’s  qualitatThe paper addresses the knowledge gap and presents the findings from a research project that explored the dynamics of poverty across the lifespan of elder-headed households, including older people living alone and those living only with a spouse. The study’s findings relating to the participants and data relevant to the older people living alone are reported here. Data were extracted and analyzed to explore the challenges and strengths of this subgroup of older adults. The findings identify the target population’s challenges and strengths and propose ways that those factors can inform interventions to enhance the quality of life for older adults living alone and in poverty.This study was approved by the Human Subjects Ethics Review Board at the Hong Kong Polytechnic University (Reference Number: HSEARS20200113002). In addition to procedural ethical protocols, we also developed a distress protocol adapted from Draucker et al.  and dying alone.“Living alone…is troublesome, no one talks with you. After having meals, I sleep, I watch TV, and then sleep again after watching TV, just like this, nothing, that’s it—you know?”  Another participant echoed this sentiment, saying:Participants also shared how their social isolation and loneliness were expressed in their everyday life routines: Living alone, you can’t even find someone to chat with. If something happens, even mundane things like my scratching an itch on my back, no one can help you with that and you can’t help yourself, either. Earlier I got the shingles, I ha[d] to beg a few times before someone would help me to apply medicine to my back.“I don’t know stuff like that.”  Another participant shared the reason why he lived in subdivided flat  Another reported: “I’m nervous and bad at talking, and uncultured and illiterate, you know? That’s what I meant when I said I’m uncultured. I don’t know stuff.”  When asked to identify what support is needed, a participant replied: “We need to feel good about ourselves.” .When asked about their perspectives and ideas about support for their well-being, the participants often responded that they had little to contribute because they lacked formal education. Common responses included:  hygiene ): “FirstDeclining mobility, health, and activity levels were other key challenges identified by the participants. As one participant shared:In recent years, my knees started to hurt a lot and my relative suggested [I] go to a nursing home. She told me to apply when the situation is not that bad because it takes a few years of being on the waiting list. It’s hard to tell when it [her knees] would deteriorate. I am worried about that, so I applied.Other participants worried that such declines in mobility and health would cause them to go out into the community less. One participant described:I seldom go out. I want to, but I can’t. Many things hinder me. I can’t walk fast. My knees make me have trouble in walking up stairs. I am scared of the stairs, so I don’t dare do many things. If you can still walk, you can find someone who can help you. If you want to talk to somebody, you can go out and find someone. How could this be achieved if you can’t walk?Another participant echoed that sentiment:I joined as a volunteer with the church to do some home visits with other older adults, but it is difficult for me to walk, I feel exhausted when I go upstairs and downstairs. I want to prevent further damage on my joints, as there is wear and tear on them. There is no other way but to have a joint replacement. I am not willing to receive the replacement, so I stopped joining those activities.Another key challenge the participants identified involved concerns over current and future medical expenses––a particular worry for older adults who had multiple health issues  and were on multiple medications. Despite access to healthcare vouchers Another participant shared:I have the Health Care Vouchers, but I have used all of them. Now I pay for it myself. It costs around 300 dollars each time I visit the doctor. It is expensive. Sometimes I just stick a band-aid on instead of seeing a doctor. It can’t eliminate the pain completely, but I will feel more comfortable.“The dit da (a Chinese medicine to treat bone-related injuries) for bad knees costs tens of dollars each. What else is left at the end of the month?” Interestingly, despite their low income, some participants reported a willingness to pay extra for private care . One participant shared: Experiencing age discrimination and/or long wait times for medical health services was another key theme in the challenges experienced by the participants. One participant shared:He [the doctor] said it was because of degeneration. This is what the public hospital doctors do: old people come to them for knee pain, and they say it is untreatable degeneration.… they did not even assess me. They said the degeneration is irreversible!Another reported:But for the x-ray, I need to wait for 5 years because I am 75 years old now. I am too old. I still did not have the scan even now. This is a long-term knee pain, I don’t have the knowledge of what to do, so I just tolerate the pain.A third participant shared:I am most concerned about my nose. I cannot sleep when I have a stuffy nose, but no doctor helps me …. I have waited for 3 years. Is it reasonable?Participants also reported experiences of age discrimination regarding employment. For instance, many shared that, despite wanting to continue to work, they felt they were pushed to retire due to their age. One participant explained:It was not “retirement.” It was because I can’t walk fast. My knees are sore. I can’t work efficiently like others—what could I do when I only closed three deals as others closed five deals? [I was] sixty-something. I can’t work efficiently. Gradually, I had conflicts with my colleagues. They felt it was unfair when everyone took the same salary while I did less. The head [of staff] also complained to me. So, I was half-retired at that time.Another shared:I was the chief writer of [name of newspaper]. The boss was rubbish. We could not get along. When I was first recruited, he promised that I would have my share. After the newspaper became well-known, he bought himself an industrial building. Once I reached 65 years old, he kicked me out and hired people who just graduated from university so he could pay less. Sneaky rubbish.Yeah. I thought about going back to work after he [her husband] died—washing dishes or something else. But they don’t hire people over sixty.”  When asked if she currently works, another participant shared, “No, [laughs] who would hire me?” .Furthermore, the participants stated that they still wanted to work, especially part-time, but struggled to find employment due to their age. One shared: “There also were two unique challenges experienced by some of the participants.“Originally it was in [neighborhood A], and there are a lot of women crowded in the room, so I go to the [neighborhood B] one instead.”  Another participant opined, “Majority of females love gathering and chatting. Men don’t. Men are lonelier and more egocentric, so they don’t get on well together.” Among the small number of older men interviewed, some shared that they did not participate in specific activities because they felt the activities were strongly geared toward older women. One participant explained why he switched locations to do his exercise: The majority of the low-income participants were living in public housing estates, with a small minority either on a waiting list or not yet qualified for public housing. For those participants, housing insecurity  was the primary concern. As one participant shared:Sometimes I can’t sleep, thinking about this [referring to his housing insecurity]. Yeah, sometimes I drink one can of beer to sleep. I used to not drink. But I have some beers in my fridge, and I’ll open one when I can’t sleep. I will not take sleeping pills.Another participant explained his housing situation:Yeah, a lot better [referring to public housing estates]. Subdivided units are a lot different from public estates. It’s much narrower and constraining. You enter a flat and it’s divided up to ten units. My life right now, to be frank, living in a subdivided unit, there’s a lot of bed bugs. They are in all the rooms. We have to spray insecticide all the time. Also, they usually come out at night. They wait for you to fall asleep for your blood. So, I write calligraphy till late, often until dawn before I sleep, and when I see a bed bug I catch it. I catch them all before I go to bed.Another participant shared that despite a bedbug problem, she was unable to move because her current building had a lift, which she needed due to her limited mobility:… more bugs in these two years, especially this year! I cannot sleep well. People keep moving in and out, but I cannot. I don’t know where I can go. There is a lift in this building, I cannot walk up and down the stairs due to my knees. My friend introduced this flat to me because there is a lift, I don’t need to walk stairs.Three key themes of strengths were common across the majority of the participants.When asked about future expectations as they aged, a common theme was the mindset of having enough. As one participant shared:I never ask too much. Living a mundane life: healthy, enough food, enough money. I don’t spend on luxurious things. So far, that’s it. Now I wait for nothing. I need nothing. The future? Not much. ‘Come quietly and leave peacefully’, I guess. [laughs] I am eighty and I am on the way to the “end of road.”Another, who had experienced the Cultural Revolution and war, shared:The condition back then was not good, and my grandpa was part of the “Five Black Categories” . We havYet another, who also had experienced the same historical contexts, pointed out:Everyone lived very poor in the past. We didn’t get to go to yum cha all the time like now. You had to be very wealthy with a house to enjoy the luxury of going to yum cha. We didn’t have three meals a day. Two meals a day is already lucky. One meal at 9 am, and another at 4 pm. Who gets three meals a day? I am over 80, I’ve seen everything. The Japanese invading, and Cultural Revolution. Now, now is the most peaceful time.“I would wish that they don’t give us so much! They are giving us HK$2000 again, soon right? The more money you spend the more you want to spend.” .One participant even shared the following in response to the recent pandemic consumption vouchers : “The NGOs are really kind. They give us free meals every Monday, Wednesday, and Friday. On Tuesday, they also give us food, like bread.”  Another shared that her local district councilor had helped her find a job and helped with other applications after her husband died:Participants also reported that their formal social support network was strong, noting that there were no shortages of NGOs, public community workers , and community organizations reaching out to them, offering social participation activities and support to meet their basic needs . One participant shared: The district councillor––He was quite nice. He recommended me to sweep the floor [referring to her cleaning job]. When I encounter difficulties, I can seek advice from him. I don’t know words well and he helped me to fill the form to apply for the Consumption Voucher Scheme [a government subsidy during the pandemic]. Their office is on the 3rd floor below us. Everyone treats me well.“The building next to us is called [Name] Building. [Name] Welfare Association is there, and they care about me a lot. Last year, they gave me a blanket. It was very cold that year. This year it is hot, and they gave me a fan cooler.” Another participant described receiving help with material goods during the different seasons: Participants also reported contributing to the community and others in various ways. One participant described accompanying her neighbor to the hospital:I offer help whenever it is within my power to. Like the one downstairs. She asks me to go to the hospital with her, so I accompany her. Once she had a surgery, I bought food for her for three months. I help out.Another participant shared a similar situation:There is one who just got into [name] Hospital. He is 84 years old, living in the [name] building. He has chronic illnesses. Last year, I was walking out[side] the building and saw him having shortness of breath, so I took him to the hospital. After he was hospitalized, I got a call saying he had a stroke. He was in a coma for over ten days, and he woke up. He had no one to turn to, so he could only call me. I do what I can do. It took about two months for him to recover. The period before he was discharged, he cried a lot to me, saying he doesn’t know what to do, whether he should go to a nursing home or not. I had no idea of what to do, so I sought help from a doctor from the place [where] I do volunteer work, in [Name] Hospital. Then [Name of Social Worker] recommended him to a nursing home. He was lucky having me to help him—of course [name of social worker] also helped a lot.“I usually do volunteer work here. I deliver meals on Sundays.”  Another participant shared how she helped out during the pandemic: “Now I contribute to the society. I join voluntary work when I have time. During these two years, we packed face masks and materials, and delivered them to other older people.” Another participant reported that she volunteered to deliver meals to homebound older adults: A small number of participants shared preferences for living alone. As one participant described:I don’t feel so sad. Right now, I feel good being alone. I have way less burden. Except if you really have someone you really love who you want to spend your life with. Or else I really don’t want to become others’ burden. There’s nothing wrong about being alone, we all come here on our own, you brought nothing, so you don’t need to bring anything away with you either when you leave, right?Another participant shared:I think it’s more freedom for myself. No one to make me angry, nothing to see, right? If I have friends over we can drink tea if we want to drink tea, watch a movie if we want. Walk around if we want. I think it’s freedom.Most of us like to be alone. [laughs]” .A third participant offered this perspective: “The study’s findings present important insights for future research and practices in Hong Kong, and can be extended to other contexts that also are witnessing a greater proportion of older adults living alone and in poverty. Thus, providing policy and practice insights locally and globally on social and cultural determinants of health. Five discussion points arose from the insights.First, the findings illustrated that medical health challenges  are a major concern for this group of older adults, and at the same time they are motivated to improve their health, with many being willing to pay for private healthcare  when the public system dismissed their needs or failed to address them, despite their low income and frugal lifestyle. Indeed, the high medical expenses related to such care (or future care) are a barrier to escaping poverty and can even deepen it. Addressing old age poverty must include a deeper examination of the role of public medical health systems. Future research should explore how age-friendly interventions within public medical health systems can impact poverty in old age.Second, the findings suggest that a subgroup exists within this already marginalized group and is at a greater disadvantage, thus requiring additional support: individuals who are not living in public housing estates due to ineligibility or being on a waiting list. This subgroup is repeatedly falling through the systemic gaps. In Hong Kong, as of March 2022, the average wait time for an older adult one-person applicant was 4.1 years . During Third, the findings shine a spotlight on employment among older adults. Current discourse regarding the older adult workforce is expansive, as societies are experiencing rapidly ageing populations . NeverthFourth, the findings suggest gender differences to be explored further. First, there is a need to more deeply examine the barriers and facilitators to social participation for older men who live alone and in poverty. The findings relating to gender differences in this study come from a very small sample of older men and cannot be generalized. However, those findings do align with other research. For instance,  found, iThe number of older adults who live alone and in poverty is increasing, in Hong Kong and worldwide. An understanding of their perspectives and lived experiences is necessary in order to better support them. Such personal experiences of ageing are undervalued in empirical research but are important in transforming older adults from mere objects of study to active participants in research. Although this qualitative study cannot be statistically generalized to all older adults living alone and in poverty, it provides in-depth and nuanced insights that elucidate the gaps in knowledge, practices, and policies. Our findings stressed that older adults who live alone and in poverty face numerous challenges, but we were limited in identifying the causes of such challenges. Still, the study highlights the interconnections among the challenges. For instance, age discrimination and long wait times for medical health services may erode older adults’ mobility, health, and activity levels, and that in turn could exacerbate their social isolation, loneliness, and poor mental health, self-esteem, and self-efficacy. The findings about the challenges reaffirm previous research, and the results regarding older adults’ strengths warn against viewing this group through simply a deficit lens and as passive recipients of care. Addressing poverty in old age and tackling the challenges associated with living alone will require focusing on and activating not only external and systemic resources but also the intrinsic capacities and strengths of older adults themselves. Lastly, this study illustrated successfully addressing health inequalities among older people, will necessitate a focus on social  and cultural  determinants of health.


The definition of ‘soundscape’ emphasises the perceptual construct of sounds; thus, the mechanism of sound perceptions becomes vital for soundscape evaluations. Using a qualitative approach, this study explored the aspects and processes of sound perceptions and built a perceptual soundscape structure from the insight of sociology. The interview was conducted between January and March 2018, in four urban public spaces. Data reached saturation after 23 participants were interviewed based on the grounded theory approach. Four perceptual aspects of sounds were identified from the semantic coding analysis: sound classification, sound features, psychological reactions, and soundscape preferences. These aspects form a three-level process of perceiving soundscapes: sound classifications, sound appraisals , and finally, judgment (soundscape preferences). Overall, four aspects categorised into three levels of perception make up the soundscape structure. Soundscape preferences are at the most profound level of perception and are informed by the previous three aspects. Soundscape preferences are expressed through descriptive words and narrative ‘image’. The ‘image’ reflects people participating in different activities according to their social background. Social relationships influence soundscape preferences through people’s sound requirements for various activities. The perceptual structure of soundscapes may provide guidance for future soundscape research and soundscape questionnaire design. The relationship between sounds and humans and the way people perceive the acoustic environment were originally emphasised to stress the ‘degradation’ of the sustainable acoustic environment due to industrial growth and the process of urbanisation ,2. EarlyIt was suggested that people perceive sounds through a systematic process . PresentOthers focused on how sound signals reach the perceptual level. Schulte-Fortkamp and Fiebig  outlinedBased on the previous studies, this study aimed to explore further the mechanism of how sound signals are interpreted to sound awareness by the urban public space users with a sociological insight. Two research aims were defined as (1) to figure out the dimensions of soundscapes in urban public spaces from the perspectives of space users; (2) to figure out the interrelationships among the soundscape elements so as to form the perceptual process. By investigating these two issues, a perceptual structure of soundscapes with different perceiving stages in urban public spaces can be obtained.The grounded theory (GT) approach has been largely used in the soundscape research to generate the understandings of sound perceptions. The GT approach is a research methodology that results in the production of a theory to explain the systematically collected data ,25. ReseAccording to the GT approach, to collect abundant research data, in-depth interviews are the key method. In this study, interviewees were selected through the convenience sampling. Convenience sampling is applied when the study site is identified but the sample size is not known. Following this sampling method, the researchers recruit samples at a targeted location by random—researchers may ask people who are present in the street, public buildings, or in a workplace . CompareDuring the research, the researcher took notes to record the sound sources heard in the sites and measured the SPL (sound pressure level). Sound sources heard in the sites included the sound of wind, bird, music, cars, and various sounds produced by people, such as talking, steps, children, etc. SPL was measured by a sound level meter . The measurements were conducted during each interview. The range of the A-weighted equivalent sound pressure levels for the four sites were listed as 65.0 dB~68.5 dB , 70.5 dB~75.8 dB , 68.5 dB~70.8 dB , 59.1 dB~60.7 dB . Both sound sources and SPL information were found to be representative of the soundscape of urban public spaces based on the previous studies . Data weAccording to the previous practice of the GT approach, the interview data were analysed through semantic coding with the successive use of open, axial, and selective coding . Those tWith various sounds in the environment, categorising them was the first thing that came to mind when participants were asked to describe soundscape. People tended to recognise sounds within a category, rather than individually. Three kinds of categorising methods emerged: (1) categorising sounds by sound attributes, (2) categorising sounds in the order in which they were noticed, and (3) categorising sounds by the information they conveyed.sounds of trees, birds, water, and wind …’ (a29). In contrast to natural sounds, participants categorised the sounds of music and bells as ‘artificial sounds’ (a85). ‘People sounds’ were also mentioned. This included talking, children’s laughing and screaming, and footsteps . The rest were categorised into the group of ‘city sounds’, such as traffic noise, wind between skyscrapers sounds, and store music . Thus, there were four categories of sounds: (1) human sounds: talking, laughing and screaming, and footsteps, (2) natural sounds: trees, birds, water, and wind, (3) instrumental sounds: music and bells, and (4) city sounds: traffic noise, wind from the urban canyon effect, and store music. This classification method represents a basic understanding of sound attributes.Categorising sounds by type was based on people’s common sense and life experiences. Nature was the most frequently mentioned; this included ‘As public squares are usually located in the city centre, various kinds of sounds from the city make up a complex acoustic environment. In such a complex environment, the cognitive process would enable people to navigate their surroundings and differentiate between salient and background sounds. The sound of water was mentioned mostly as a foreground sound, and some participants considered it to be so loud as to mask background sounds (a87). Background sound included faraway sounds, such as the sounds from surrounding shops and amusement facilities . It seems that participants generally distinguished between foreground and background sounds based on volume.sounds from the amusement park nearby’ and ‘promotion campaign sounds’  were emphasized. Although the background sounds mentioned were quite far away from the square, they were required to fit in the overall soundscape of the square to create a satisfactory sound level. The positive influence included ‘Water from the surroundings echoes with the water sounds here, which makes a connection’ (a16). Compared to the negative effect, when the surrounding sounds were positive and in harmony with the foreground sounds, they were considered to have a positive effect.Some participants mentioned that background sound had both a negative and a positive influence on the whole sound environment. Background sound could be annoying when it disturbed the overall soundscape; for example, because Guanqian Square is located inside the commercial centre, the annoying ‘The various pieces of information contained in sounds were used as a classification method because sound is a medium for conveying information. As information tends to be time-sensitive, information-related sounds were categorised into two types: (1) current information, where listeners could learn about events and situations that were happening at the moment, for example, clock bells providing information about the time (a101) and (2) past information, or sounds associated with memories. For example, typical water sounds in the Peace Garden were reminiscent of people’s memories (a19). Store music was also believed to trigger memories because of some old songs that were played (a20).In short, classification is fundamental to how people understand sounds. Compared to the classification methods used in previous research, the one used in the present study did not involve delving deep into the physical attributes of sounds, such as strength and fluctuation . The thrFaced with multiple sound sources in the square, participants tended to think of the relationship between individual sounds and the overall sound environment. They concluded that there are two kinds of relationships: the ones between diversity and integrity and between particularity and stereotypes. The first one refers to people’s recognition of the coexistence of multiple sounds and the requirement for those sounds to be harmoniously combined into an integral whole; the other indicates that people had a requirement for the particularity of a sound to identify the square, but they did not want this particularity to exceed their general understanding of the soundscape of the square. Both relationships show how people thought logically and critically about the characteristics of the square’s soundscape.Firstly, a wide range of sounds was recognised as a positive feature of the square’s soundscape . In addition to the diversity embodied by multiple sound types, variations in the tone and volume of the same sound can also bring diversity. Fountains were mentioned as showing this kind of diversity, as the changing water flow can bring with it various sounds (a78). Sound tone was mentioned with reference to bird sounds, as some birds can make changeable sounds (a51). People even thought that the more varied the sound, the better (a56).mix well together’ ‘in a natural way’ . Thus, they stressed ‘integrality’ . For the sake of this wholeness, particularly ‘harsh’ sounds, such as sudden sounds  and high-volume sounds  , were considered to require improvement.Although many people viewed diversity as positive, others felt that too many kinds of sounds can confuse listeners. Some people expressed that too many sounds mixed at a time can be noisy. They mentioned that no more than three kinds of sounds are acceptable . Others accepted more types of sounds as long as they ‘People desired that the square soundscape be unique, but at the same time, they required it to conform to the stereotypical attributes of a square. One of them did not like store music because it was too popular to be featureless (a20). The sound of water was praised as it represented Sheffield’s character. The ubiquitous water sounds were believed make the city more memorable .Sound types in this public space are all basic sounds, very common; fountain, children, talking are ordinary sounds in the public space’ . Interviewees mentioned that they wanted the other environmental factors  to match the sound environment. In return, they did not ask for a perfect sound environment. Instead, they considered commonness to be even better (a50). As a result, some unusual sounds were considered unacceptable, such as loud music. Loud music was recognised as ‘a sound only found in pubs’ (a86), and therefore inappropriate in the square. People might wish for each place to perform its functions and to have its standards. To sum up, stereotypes and particularity are not contradictory: what people want is the particularity within their square stereotype.On the contrary, participants had limited imagination regarding what constitutes a general square soundscape. They displayed a similar, uniform understanding of the square soundscape, for instance, ‘Sounds can bring about psychological reactions, and participants tended to describe the soundscape by describing the feelings that sounds triggered. A soundscape was found to bring about two kinds of subjective reactions: (1) instant and transient and (2) relatively stable and prolonged. In response to sound-induced subjective reactions, especially negative ones, participants adopted strategies of tolerance, avoidance, and complaint.speaking, birds’ singing, children screaming , skyscraper effect sound, wind (a40); (2) awkward: others’ conversation, music on others’ phones ; (3) relaxed, calming, peaceful: waterfall, fountain, sounds representing nature ; (4) unsafe, worrying: car brake, bus ; (5) energetic, exciting, lively, vivid: dancing music, children playing and screaming ; and (6) sociable: festival music (a14). In addition to the particular sound source, the visual aspect was tightly combined with sounds in the aspect of triggering a particular feeling. For example, the image of children playing accompanied by the sound of children screaming triggered a happy feeling. Meanwhile, the interviewee would not feel happy if they only heard screams (a77).Instant psychological reactions were found to be triggered by particular sounds in the square: (1) happy/depressed: quiet’, the feeling of ‘tranquillity’ is long and stable (a77). In addition, as public squares are mostly located in city centres, people mentioned that they felt depressed (a34)/depressed (a90) when facing all the high-rise buildings (a34). This feeling was not triggered by particular sounds, but was related to their living conditions. By contrast, the sounds of nature eased anxiety. People mentioned that they came to the squares to experience nature and to get rid of their working space .Prolonged psychological reactions are relatively stable compared to the instant reactions. For example, unlike the instant feeling of ‘Psychological reactions were found to influence both mental and physical aspects. Calm sounds can made people think, for example, rainy sounds (a49). Happiness, on the contrary, was associated with physiologically perceived warmth (a66). Similarly, a calm and tranquil feeling brought about by the water sound was believed to reduce the temperature in hot days (a22).Positive feelings were found to provide restoration and benefit mental health. Fountain sounds were found to bring positive feelings and relieve people from stress (a69). Public spaces with large areas of greenery can reduce urban noise and bring with them calmness (a25). While, the consequences of negative feelings were more far-reaching and severe, with potential long-term negative effects on psychological and physical aspects. Anxiety aroused by traffic noise made people physically uncomfortable (a52). The sounds of loud laughter and shouting from groups of teenagers cast a long psychological shadow over one of the participants (a32).Three strategies for coping with negative emotions were summarised from the interviews: tolerance, avoidance, and complaint. Tolerance was adopted when people felt that they could not change the situation, and they finally accepted it. Such strategies were often adopted in response to traffic noise, which people considered unavoidable in cities . When people felt that they could not cope with unwanted sounds, they would choose avoidance. Some of them considered it a way to control the situation as they thought they had the option to leave. As long as they could leave the place at any time, they felt everything was under control, and they would not feel stressed about the unwanted sounds anymore . Others chose to complain about negative sound experiences (such as posting on the website), and they gave suggestions in an attempt to improve the future sound environment (a55); . In short, these three strategies cover people’s psychological adaptation. When people were met with noise problems, they tended to solve problems at the psychological level.People were found to express their preferences for the total acoustic environment in two ways: through adjectives or descriptive phrases and through ‘image’ description—expressing soundscape preferences by narrating an event in the square, in which sounds appeared as a part of the ‘image’.People used phrases or adjectives that directly point to the preferred/annoyed sound source or preferred/annoyed feelings brought about by sounds. ‘Preferred’ or ‘annoying’ is an essential measurement by which people understand and evaluate sounds. It was also found that soundscape preferences contained judgment about their preferences for the three aspects mentioned above: sound sources, features, and psychological reactions. As shown in Preferences about soundscape features were ‘various’  and ‘harmonious/united’ (a28) in the aspect of diversity and integrality and ‘distinctive’ (a20), ‘typical’ (54), and ‘appropriate’ (a86) for particularity and stereotypicality. The preferred psychological reactions were mostly those associated with positive emotional feelings, such as happiness and relaxation.relaxing, peaceful’ (a4); and ‘nature sounds’ ‘accompanied’ (a85). The ‘couples image’ was generally concerned with quietness and a private sound environment . In these images, soundscape preferences also included judgments of the above three categories, such as relaxing , nature sounds (sound classification), and hearing sounds not belonging to the square (stereotype).When people felt that it was challenging to describe the preferred soundscape, they described an ‘image’, including information of ‘who’, ‘where’, and ‘doing what’. The word ‘image’ was originally mentioned by one of the interviewees when she described how she had a great soundscape experience with her children in Peace Garden (a77). ‘Image’ referred to the phenomenon that respondents tended to describe their expectations and desires for soundscapes based on their life experiences and knowledge of the world. Various pieces of socio-demographic information were included in these ‘images’, such as occupation, age, gender, and social relationships. Social relationships were dominant, as activities were centred around them. People’s activities were found to correspond to their social relationships. Categorised by social relationships, three types of ‘images’ emerged: those pertaining to friends, family, and couples. People mentioned an ideal ‘friend image’ with an eventful soundscape in relation to vacation, festivals, and performances (a14); (a97). The ‘family image’ involved a soundscape that was ‘Socio-demographic information is usually considered to influence people’s soundscape preferences . In the The perceptual structure of soundscapes includes perception aspects and the perceiving process. According to The perceptual structure stresses two points about the soundscape: first is that there is a hierarchy in people’s perceptions of sounds, whereby the four aspects form three progressively more profound levels of sound perceptions; second is that soundscape preferences entail value judgment about the sound classification, features, and psychological reactions through descriptive words and narrative ‘image’.The perceptual structure generated in this study has associations with previous research in the environmental psychology field. The process of perceiving sounds corresponds to Rapoport’s  process Three levels of perceiving the physical environment are also seen in Morris & Boulding’s  ‘image’ Social relationships are the dominant aspect of the ‘image’ of sound because they influence people’s soundscape preferences through the activities they engage in. People tended to require the soundscape to support their activities. This corresponds to Gibson’s  affordanThis study aimed to explore the aspects of the perception process in order to build a perceptual structure of soundscapes for public space users. Based on the grounded theory approach, four aspects were summarised: sound classification, features, psychological reactions, and preferences. (1) Sound classification: the way people categorise sounds reflects the fundamental understanding of sounds. Ordinary listeners tended to categorise sounds by content and sound levels. (2) Sound features: people can think dialectically about the relationship between individual sound and the overall soundscape. (3) Psychological reactions to sounds: sounds trigger instant or prolonged psychological reactions, which can result in physical and psychological outcomes in listeners. To deal with the negative outcomes, people adopt the strategies of tolerance, avoidance, and complaint. (4) Soundscape preferences: people were found to express preferred sounds by descriptive words and narrative ‘images’. ‘Image’ preference indicates the approach towards perceiving the physical world. The dominant status of social relationships found in the ‘image’ reflects the social attributes of people in the square’s activities. Social relationships influence sound preference through people’s sound requirements for different activities.Based on the previous studies, especially the ISO’s perceptual construct of soundscape, this study focused on the aspects and process of the urban public space users perceiving, understanding, and experiencing sounds from the insight of sociology. The perceptual construct of ISO is based on the psychological theory, which explains how humans respond to the external stimulus with feelings and responses/behaviours. Sound is understood as one of the external stimuli, and soundscape exists through human perception of the acoustic environment. The perceptual structure of soundscape summarised in this study expanded the ISO’s structure to explore how a socially constructed listener transforms auditory signals into sound awareness. Four soundscape aspects categorised by three levels of perceiving progress make up the perceived sphere of sounds: classification—sound appraisals —judgment (soundscape preferences). Sound classification represents a basic understanding of sounds. Appraisals involve functional and emotional evaluations of sounds, representing rational and emotional thinking. In the end, soundscape preferences are generated based on the knowledge of the previous three aspects. The two descriptive methods of soundscape preferences reflect listeners’ desires and expectations for soundscape based on their social relationships, social roles, social status, etc.The four perceptual aspects summarised in the GT approach provide a comprehensive view of sound perceptions. The three-level perception process offers the possibility of analysing soundscapes from various perspectives. During the judgment, two methods of describing soundscape preferences were found in this study, descriptive words and narrative ‘images’. These two methods expand the scope of soundscape preferences and evaluations. For example, in soundscape studies that aim to simulate the urban public space environment in laboratories, it may be possible to better recreate the scene of public spaces by carrying out some activities. Social relationships emphasised the preference for ‘image’, and the influence of companionship should be explored in future studies. However, owing to the limited human resources, this research neither included various kinds of urban public spaces, nor covered a variety of seasons; thus, the perceptual structure of soundscapes derived from this study may not be generalisable to all kinds of urban public spaces under all conditions. The factor of season can influence the activities of humans and animals in urban public spaces, thus affecting the acoustic environment. Further studies in other kinds of urban public spaces across the different seasons are required to enrich this structure. Additionally, this study involved different urban public spaces across the countries, which brought variances in site context. The site and cultural differences were not adequately compared and analysed as this study was concerned with the dimensions and overall process of how the public space users perceive sounds. The selected sites with cultural differences were intended to increase the sample’s diversity so as to dig deep into the perceptual sound sphere, rather than to make case comparisons. Future research must attempt to fill this gap.


Transgender and gender diverse (TGD) people experience stigma, discrimination, trauma, and post-traumatic stress disorder (PTSD) at higher rates compared to the general population; however, TGD people have been underrepresented in PTSD research. Clinical trials of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy demonstrate promising safety and efficacy for the treatment of PTSD. Issues related to equitable access, power imbalances in the therapeutic relationship, and vulnerable states of consciousness occasioned by MDMA are magnified when working with people affected by structural vulnerabilities and health disparities, and community engagement in research planning and implementation is essential. To inform the inclusion and safety of TGD people in future MDMA-assisted psychotherapy research, the aims of the current study were to: characterize TGD experiences with trauma-related mental health care, assess openness of TGD people to participate in experimental PTSD research, and to gather specific feedback on protocol design for conducting MDMA-assisted psychotherapy with TGD people.N = 17). Eligible TGD participants had a history of receiving trauma-related mental health care. Each FGD was facilitated by two licensed clinicians who identified as TGD. Qualitative data analysis was conducted via an iterative process of identification of recurrent patterns and themes.We conducted three virtual focus group discussions (FGDs) with 5–6 participants each (We have identified several key issues TGD people face when seeking and engaging in trauma-related mental health care, including barriers to receiving adequate gender-affirming and trauma-informed mental health care and frustration with providers lacking cultural humility. Suggested amendments to MDMA-assisted psychotherapy protocols include: routine collection of trans-inclusive gender identity data, implementing an explicit gender-affirming treatment approach, ensuring a culturally safe setting, and diversifying co-therapy dyads.The inclusion of TGD voices in early conversations about emerging experimental PTSD interventions promotes equitable access, in the context of health and healthcare disparities, and helps researchers understand the needs of the community and tailor research to meet those needs. Through an ongoing conversation with the TGD community, we aim to incorporate a gender-affirming approach into existing research protocols and inform future applications of MDMA-assisted psychotherapy in addressing the effects of minority stress and boosting resilience. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013 and replaced with “gender dysphoria.” This, and other positive shifts in terminology in the most recent DSM-5-TR , aim to help destigmatize TGD identities while maintaining healthcare access for those who need it (Transgender and gender diverse (TGD) people experience violence and trauma exposure—and subsequent post-traumatic stress disorder (PTSD) and suicidality—at higher rates than the general population , 2. Tran need it , 5. None need it –8.Throughout recorded history, hundreds of distinct cultures have recognized third, fourth, fifth, or more genders; while the gender binary that exists in most Western societies is a relatively new construct . “Cisgen3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy is an innovative experimental treatment for PTSD with promising results from Phase 2  and PhasAs noted by recent psychedelic research focused on the inclusion of people of color –16, tradFor studies involving participants affected by structural vulnerabilities, the National Bioethics Advisory Commission recommends including the community at various points in the research process—particularly during the study planning phase . To achiWe conducted three 90-min virtual focus group discussions (FGDs) in February and March 2021 using WebEx video conferencing. Focus group discussion participants were recruited from a medical university's Transgender Health Program, a Veterans Affairs Sexual Orientation and Gender Identity Advisory Group, and other community organizations focused on providing services and community for TGD individuals. To limit selection bias, we did not mention MDMA or MDMA-assisted psychotherapy in recruitment materials. Participants were compensated $50 upon completion of the FGD. This study was conducted in accordance with the Declaration of Helsinki and was approved jointly by the Oregon Health and Science University and the Veterans Affairs Portland Health Care System Institutional Review Boards.N = 17) consisting of TGD people . All had previous experience receiving trauma-related mental health care. Additional inclusion criteria were: (a) age ≥18 years old, (b) currently located within the United States, (c) fluent in English, (d) able to navigate WebEx and provide safety information , and (e) available during one of the three scheduled FGDs. See We enrolled a sample . Another participant reported on a positive experience with an empathic provider who had neither lived TGD experience nor particular expertise in TGD health care, distinguishing the provider from systemic issues:Several participants reported on positive experiences, particularly with mental health care providers who were TGD themselves or had a lot of experience working with TGD populations. Although one participant noted, “It was about someone being an ally to me in the process of moving through systems that were not inclusive. Which is not something that's always thought of as good therapy, but some of the best therapy I ever had. Feeling affirmed at someone standing up for me like that, and me not having to do it. So…and then from that, a lot of trust and a lot of beautiful conversations that helped me to work through things. (P12).You have to pay out of pocket or have a job with good insurance to get that kind of therapy.” (P4). Often, participants had to utilize whatever trauma-related mental healthcare resources were available to them through their insurance or healthcare plan. Participants mentioned barriers to receiving trauma-related psychotherapies other than cognitive behavioral therapy , such as lack of insurance coverage or institutional support for alternative modalities. One participant noted the high turnover within a public psychiatry clinic, “there needs to be like, a warning, so I can prepare for that, and we can finish out our sessions properly instead of cutting me and taking progress with them.” (P6), and the subsequent dice roll when getting matched with a new provider. Another person commented on a related issue affecting access for TGD people, “it's a small community, and so when you seek care as a person in that community from people in the community, it's just more awkward. It's more difficult.” (P8). The potential for dual relationships with TGD providers presents an added challenge of navigating issues with confidentiality, communication, and boundaries.A primary theme was the general lack of available trauma-related health care with providers who were culturally aware of TGD issues. “I don't like having to explain everything ‘cause they could Google things themselves.”' (P4). Some chose to conceal their TGD identities from providers they sensed were unfamiliar with, or even hostile toward, TGD people. Reflecting on a history of TGD people being systemically pathologized within the medical system, one participant noted:Another theme was negative experiences with trauma-related health care providers. Many participants were frustrated with having to educate providers on basic TGD terminology and concepts. “It seems to me that, you know, many in the mental health field still regard us as mentally ill. They don't see us as…the diversity of what human beings can be. You know, because they're so binary themselves, so they're seeing the world through a binary lens—which makes it difficult for them to empathize with those of us [who] are outside of that. (P1).Another participant in their late 30s described their experiences of mental health treatment during childhood and adolescence:I just went through the system for a very long time with a lot of like, very cisgender, white, older, male therapists. And they were…very harmful, and sort of like dictated what was wrong with me…there just wasn't like breathing room to kind of know, or have a space in which to, to explore who I was, you know? I feel like I was really told who I was through therapy for years.” (P11).“Participant awareness and familiarity prior to the FGD of MDMA-assisted psychotherapy for PTSD was normally distributed. Three participants reported complete unfamiliarity, ten participants reported that they had heard of it or knew a little bit, three said that they knew a lot about this modality, and one did not disclose prior knowledge or lack thereof. Initial impressions ranged from enthusiasm to concern.I'm absolutely obsessed with this. Not just MDMA, but, like, you know, I really love the work that MAPS [Multidisciplinary Association for Psychedelic Studies] is doing. I love the research that's around it.” (P11). A few participants described their own personal experiences with MDMA or other psychedelics, including, “I've had a lot of my own personal experiences with psychedelics, with MDMA specifically, that have been profoundly moving and life-changing. I've been staying up on the research.” (P8).One participant stated, “Others were more neutral or ambivalent:So, I was just saying, yeah, after, like, years of treatment-resistance and trying all the different types of therapies, all different kinds of medications, you get to a point where you're pretty much willing to try anything.” (P3).“I'm not opposed to it, like, I think it could be really helpful. I think. I'm not sure if it's something I would personally do, but I think I could see it being really beneficial for people.” (P9).“Participants also voiced several initial concerns. Multiple participants asked if current medications would need to be stopped prior to participation in MDMA-assisted psychotherapy. Conversely, a few participants were in addiction recovery and felt this would prevent them from seeking treatment with MDMA-assisted psychotherapy. In the words of one participant:For me personally, one of the best decisions in recent times is actually to make a choice for sobriety, so I think it would be hard for me to really seriously consider it because I…just don't really engage in any substances for a time already and I would kind of like to keep that going, I guess.” (P7).“Another participant added that they would still support this as an option for others:I know it's something that I would never do. I'm straight edge….I do think that there's room for a lot of great and positive stuff to happen there and I want people to have access to it.” (P10).“Lastly, concerns were voiced around vulnerable populations receiving experimental treatments, which is reflective of historical harms and ongoing mistrust in healthcare settings. One participant referenced a series of covert and illegal projects conducted between 1956 and 1971 by the United States Federal Bureau of Investigation targeting groups that were deemed to be subversive:…using Veterans and at-risk groups as guinea pigs is really triggering for people of color like me, because you have things like COINTELPRO [an abbreviation derived from Counter Intelligence Program] and stuff they did in the past, and I'm like, ‘I don't know how I feel about that.”'(P4).“Participants offered several recommendations for future protocols of MDMA-assisted psychotherapy for TGD people. One major piece of feedback involved ensuring the screening process utilized gender-inclusive questions and phrasing . For exa…the super clinical setting is very uncomfortable for a lot of people with medical trauma, which is very common in the queer/trans community. We have all been injured at one point or another by the medical community….I don't want to be in a hospital room while I'm on MDMA. I just don't.” (P8).“Several comments challenged the historical protocol requirement of male-female therapist dyads. While this practice may have originated to protect patients, FGD participants offered alternative suggestions to avoid harm to TGD people, such as:I think that it sends a binary message. I think it should be the most qualified people that should be facilitating. It should be—if they're both males, let them be both males. If one's a trans man and one's a cis woman, let them be that. If one's a trans woman and the other one's a trans man, let them be that. You know? Whoever, whoever's qualified to run the show.” (P1).“Another participant acknowledged more recent changes in the male–female therapy dyad:I know that MAPS has edited their protocol—they used to do one male therapist and one female therapist. And having the option of having whoever you feel comfortable with—a non-binary person, a trans person…is helpful. I know that more folks are getting trained. I know that that's, you know, just been a process, but that I think would be important to me in seeking care…” (P8).“Participants expressed a mix of interest and hesitancy regarding a group therapy protocol. While some were concerned about possibly becoming overwhelmed in a group setting, others were excited by the possibility of moving through the protocol alongside other TGD people. One participant voiced:…a lot of people who go through a program like this are going to find it helpful to talk to other people with similar lived experience. And maybe not similar lived experience, but a shared experience of having taken the MDMA. I think it can be really helpful to process the things that come up with a group of people that you feel safe and comfortable with.” (P8).“n = 16) ratings revealed a moderate-high interest in “generally participating in trauma-related research,” Mean(SD), 7.76(2.82), and similar ratings for “specifically participating in MDMA-assisted psychotherapy research,” 7.44(3.41).In a follow-up email survey, participants were asked to rate “How interested are you in participating in a research study in general  in which you would receive an experimental treatment for trauma-related mental health issues?” and “How interested are you in participating in research in which you would specifically receive MDMA-assisted psychotherapy that has been culturally adapted to gender diverse communities” on a scale from 0 to 10. Average respondent . Participants engaging in abstinence-based recovery stated that they were not likely to take MDMA—a “mind-altering substance”—as part of their PTSD treatment, despite protocols including only two or three dosing sessions. This is certainly a reasonable approach; although, recent pilot data suggests that MDMA-assisted psychotherapy could also be efficacious for the treatment of alcohol use disorder . SynergiHistorically, research with psychedelics has not been exempt from contributing to medical harms against TGD and sexual minority people. For example, psychedelics have historically been paired with “conversion therapy,” based on the assumptions that TGD identities and diverse sexual orientations are mental disorders and should be “repaired” . ConversDSM criteria, which centers on a single traumatic event. This method has been critiqued for conceptualizing the effects of trauma as individualized pathology as well as for not accounting for repeated or chronic experiences of oppression and violence . Further research would be required.Due to stigma and systemic discrimination, TGD people experience a disproportionately high burden of trauma and PTSD. Targeted interventions are urgently needed to address health and health care disparities among TGD people, who have historically been excluded from PTSD intervention research. By including TGD people early in the research design and planning phase, this study aims to promote equitable and safe implementation of experimental PTSD intervention research. 3,4-MDMA-assisted psychotherapy is a promising emerging area of PTSD intervention research, and most of our FGD participants expressed a strong interest in participating in such research; while a few were not interested in participating for both personal and structural reasons. Amendments to current protocols for MDMA-assisted psychotherapy—such as an explicit gender-affirming treatment approach, a setting that is inclusive and culturally safe, and diversification of co-therapy dyads—will serve to promote safe and equitable access for TGD people. Future clinical trials that routinely collect trans-inclusive gender identity data and directly recruit TGD people will advance our ability to address health disparities and boost resilience factors.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Oregon Health and Science University and the Veterans Affairs Portland Health Care System Institutional Review Boards. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.CS acquired funding and contributed to the conception, design, data acquisition, and data analysis. MB analyzed data. DA contributed to the design and data analysis. MC contributed to the conception, design, and data acquisition. JS contributed to the conception and design. All authors contributed to the article and approved the submitted version.This study was funded by the Oregon Health and Science University, Department of Psychiatry through the 'OHSU Psychiatry Department Seed Money Grant. Additional salary support for CS was provided by the Department of Veterans Affairs, Clinical Science Research and Development, Federal Award Identification Number IK2CX001495.Author CS is a paid clinical supervisor and trainer for MDMA-assisted psychotherapy with the MAPS Public Benefit Corporation. The remaining 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. The handling editor JM declared a shared affiliation with the author JS at the time of review.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.