Chat with us, powered by LiveChat Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 78, No. 2, June 2001  | Max paper

Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 78, No. 2, June 2001
 2001 The New York Academy of Medicine

Needle-Exchange Participation, Effectiveness,
and Policy: Syringe Relay, Gender, and the
Paradox of Public Health

Thomas W. Valente, Robert K. Foreman, Benjamin Junge,
and David Vlahov

ABSTRACT Needle-exchange programs (NEPs) have been politically controversial, and
most studies have focused on evaluating their effectiveness on human immunodefi-
ciency virus (HIV) transmission rates with little emphasis on the process of how they
are used. This article shows that the way intravenous drug users use NEPs may influ-
ence their effectiveness. Using data from Baltimore’s NEP, participants (N = 2,574)
were classified as low, medium, and high users based on the volume, frequency, and
duration of contact with the NEP. Higher NEP use was associated with shorter sy-
ringe circulation times and less syringe relay, returning syringes to the NEP originally
acquired by someone else. For a subsample that was HIV tested (N = 262), syringe
relay among women was associated with HIV seroconversion (at a 95% confidence
interval). We conclude that exclusive use of the NEP (no relay) provides greater HIV
protection than NEP use involving syringe relay. The paradox is that public health
goals will not be achieved by prohibiting syringe relay activities and promoting exclu-
sive use. NEPs should broaden their education efforts to have participants understand
the value of repeated visits to the NEP.


Needle-exchange programs (NEPs) were initially developed clandestinely with mar-
ginal resources and frequent political resistance over the past 15 years. In the past
decade, more formalized programs have been developed, accompanied by more
rigorous evaluation. For the most part, NEPs have been shown to be effective in
preventing parenteral transmission of human immunodeficiency virus (HIV) infec-
tion among injection drugs users (IDUs).1–6 NEPs are designed7 to reduce HIV risk
by (1) increasing circulation of sterile syringes in an IDU community and reducing
the circulation time of possibly contaminated syringes and (2) providing programs
designed to promote individual HIV prevention behaviors. In some ways, these two
goals are somewhat contradictory since focusing on syringe circulation implies a
population public health perspective in which effectiveness is based on increased
access to clean syringes, with less emphasis on individual behavioral change. In

Dr. Valente is from the Department of Preventive Medicine, Keck School of Medicine, University of
Southern California, Los Angeles; Mr. Foreman is from the Center for Communication Programs, Johns
Hopkins University, Baltimore, Maryland; Mr. Junge is from the Department of Anthropology, Emory
University, Atlanta, Georgia; Dr. Vlahov is from the Center for Urban Epidemiologic Studies, New York
Academy of Medicine, New York City.

Correspondence: Thomas W. Valente, Department of Preventive Medicine, Keck School of Medicine,
University of Southern California, 1000 S. Fremont, Building A, Room 5133, Alhambra, CA 91803.
(E-mail: [email protected])



contrast, NEP behavior change programs focus on individual protection, encourag-
ing repeated individual contact with NEPs for behavioral change counseling and
HIV service referral, in addition to getting clean needles.

These parallel goals have led to two types of needle-exchange activities, ex-
change for exclusive use and secondary exchange. Exclusive users acquire syringes
at the NEP primarily for their own personal use. Exclusive users can derive the
most benefit from the NEP since they get clean syringes and repeated counseling for
behavior change. NEPs that expect exclusive use, however, have two limitations: (1)
IDUs usually consume drugs and socialize in networks,8–11 so users will want to
exchange syringes for one another as well, and (2) exclusive exchange is not an
efficient way to get clean syringes to a large number of users.12 These limitations
have prompted many NEPs to tolerate secondary and satellite exchange, but for
different reasons.

Secondary exchange occurs when a network of IDUs sends one person to the
NEP to get needles for the group. The disadvantage to secondary exchange is that
only the index person develops sustained contact with the NEP and access to the
ancillary services it provides. Moreover, the information received at the NEP by the
index person is not reinforced by other nonattending network members. If network
members take turns attending the NEP, it dilutes the effect of individual contacts.
These disadvantages are further exacerbated by satellite exchange.

Satellite exchange occurs when NEP participants acquire a high volume of sy-
ringes to sell or trade outside their personal network in neighborhoods distant from
the exchange.12 Satellite exchange is conducted by individuals who are either highly
altruistic or entrepreneurial who take syringes to locations not reached directly by
the NEP. Satellite exchange provides a public health function by getting clean sy-
ringes into the community and dirty used syringes back to the exchange site. This
macrolevel impact provides a “blanket of protection” by reducing the time syringes
circulate in a community.

The paradox for NEPs is that they should encourage exclusive use to promote
the individual benefits of NEP participation, but must also tolerate, and perhaps
encourage, secondary exchange to meet public health goals. Exclusive use yields
more contact time with NEP staff trained in HIV prevention and treatment referral.
NEP impact is then demonstrated, with increased knowledge and skills among
those who visit the program frequently.1 Secondary exchange yields less direct con-
tact with NEP staff for most users, yet more potential impact at the community
level. This impact may be demonstrated by aggregate decreases in the circulation
time of used syringes and/or a reduction in HIV incidence or prevalence at the
community level.13

A key evaluation question for NEPs, then, is to show how they work at both
the individual and community levels and how to improve outcomes at both levels.
Understanding how and for whom NEPs are differentially effective may provide
some guidelines to improve their operational effectiveness. This article determines
the extent NEP use was associated with exclusive versus secondary exchange and
how it was associated with syringe circulation times. We then link these use pat-
terns to data on HIV seroconversion for a subsample. It was hypothesized that
exclusive users, because of less contact with others and more direct sustained con-
tact with the program staff, are more likely to derive individual benefit from the
NEP, as measured by HIV seroconversion.

It is not possible to measure exclusive use explicitly since it would require a
complete trace on each needle distributed to an IDU to determine whether it was


used by a participant and then returned or whether it was given, traded, or sold to
others. It would also require that we then determine whether this other person was
a member of the NEP participant’s immediate social circle and whether this other
person also visited the NEP. Consequently, exclusive use was measured by a proxy
that indicates the degree that a NEP participant returned personal syringes or those
initially distributed to someone else.

To measure NEP exclusive use, we introduce the concept of “syringe relay.”
Syringe relay refers to returning syringes to the NEP that were originally issued to
someone else. Individuals who engage in syringe relay do not return the syringes
they were given, but rather return ones from a variety of people and/or sources.
Exclusive users will have low levels of syringe relay since they will return syringes
they acquired originally. The technique used to measure syringe relay is borrowed
from Kaplan and Heimer’s method of affixing bar codes to the syringes distributed
by specific NEPs.14,15

In the Baltimore Needle Exchange Program (BNEP) in Maryland, syringes are
provided at three locations on a one-to-one exchange basis with no limit. To evalu-
ate the impact of BNEP use patterns, participants were categorized based on the
volume, frequency, and duration of their BNEP use. We then determined the factors
associated with BNEP use and whether the BNEP was differentially effective for
different users. The general model tested was whether BNEP use influences syringe
circulation time and syringe relay behavior, both of which were expected to influ-
ence the incidence of HIV infection.


There were 5,369 participants who visited the BNEP at least once during the 30-
month period from August 1994 to February 1997, a period when all distributed
syringes were individually bar coded. From this group, participants who visited the
BNEP only once (n = 1,910), participants who did not return any program needles
issued at the BNEP (n = 873), and participants who were missing any sociodemo-
graphic information collected at their registration interview (n = 12) were elimi-
nated from the analysis. The final sample consisted of 2,574 BNEP participants
who visited the BNEP on more than one occasion and returned syringes issued by
the NEP.

From the total BNEP participant list, 484 (9%) individuals were systematically
recruited into a subsample cohort that was voluntarily and repeatedly tested for the
HIV antibody. In this subsample, 141 (29.1%) were HIV seropositive at enrollment
and thus were eliminated from analysis, and an additional 81 (16.7%) did not
return any BNEP syringes and also were eliminated from analysis. The final tested
subsample consisted of 262 participants who were periodically and voluntarily
tested for HIV, were seronegative on enrollment into the BNEP, and returned at
least one program syringe. There were 12 participants (4.6%) who seroconverted
over the 30 months, yielding a 1.8% person per year rate.

On enrollment, participants were administered a short registration questionnaire
that measured sociodemographic characteristics such as sex, age, cohabitation sta-
tus (whether the participant lived with someone), whether the person lived in his


or her own residence, race, and employment status. The questionnaire also asked
about frequency of drug use within the prior 2 weeks and collected information on
speed, cocaine, heroin, “speedballing” (i.e., combining heroin and cocaine in the
same syringe), and any other drugs. Frequencies were then averaged into a drug use
frequency scale. For the tested subsample, dates of the HIV test were included in
the analysis since participants who were in the study longer had more opportunity
to become HIV infected (surveillance bias).

Baltimore Needle Exchange Program Use
Use of the BNEP was measured by dichotomizing the following three use variables16

on their median: (1) volume, the total number of syringes exchanged at the NEP
(median = 94 needles); (2) frequency, the number of visits to the NEP (median = 5
visits); and (3) duration, the number of days between first and last visits (median =
262 days). We defined BNEP use as low, below the median on all three indicators
(n = 770, 29.9%); medium, below the median on any one of the three indicators
(n = 941, 36.6%); and high, above the median on all three indicators (n = 863,
33.5%). For multivariate analysis, we converted all three indicators to standardized
z scores and summed them to get a standardized variable called BNEP use.

Syringe Relay and Circulation
Data were also collected linking individual identification (ID) numbers and the
unique bar codes affixed to the syringes acquired and returned. These data allowed
us to create a matrix of linkages in which each cell represents whether two individu-
als ever acquired and/or returned the same needle. For example, persons with ID
24 and ID 18 in the study could be linked by five needles that person 24 acquired
and person 18 returned and by nine needles that person 18 acquired and person 24
returned. In addition, each person in the study can be characterized by the number
of needles that person acquired and returned with no (presumed) intermediaries.
From these data, we created a dummy variable, syringe relay, that indicated partici-
pants who only returned syringes originally issued to someone else. We also created
a variable, circulation time, which is the average number of days the syringes issued
to a participant circulated before being returned to the BNEP. (Circulation time
could also be calculated using the number days a needle circulated that was re-
turned by the participant or the average of the two.) Syringe relay and circulation
time were used to test hypotheses concerning the effectiveness of BNEP use.


Table 1 shows the demographic characteristics of the samples. Most of the partici-
pants were male (72.0%), were older than 35 years (81.3%), lived alone (68.8%),
did not live in their own residence (61.1%), were African American (89.9%), were
unemployed (91.9%), and were daily drug users (49.1% used once a day or more
frequently). Syringes circulated in the community an average of 29.4 days. Of the
sample, 31.1% were syringe relayers. The demographic characteristics of the tested
subsample were similar to those of the larger sample.

The 2,574 participants acquired an average of 275 (SD = 592) needles during
an average of 13 (SD = 19) visits over the 30-month period of study. (The data on
the number of syringes acquired were derived from the records of needles that were
bar coded and eventually returned to the BNEP. These syringes represent only
about a third of the syringes distributed during this period; the other bar coded


TABLE 1. Demographic characteristics

All participants subsample

(N = 2,574), (N = 262),
Characteristic n (%) n (%)

Male 1,853 (72.0) 176 (67.2)
Female 721 (28.0) 86 (32.8)

Age, years
22–35 483 (18.8) 51 (19.5)
36–45 1,271 (49.4) 130 (49.6)
46+ 820 (31.9) 81 (30.9)

No 1,775 (69.0) 170 (64.9)
Yes 799 (31.0) 92 (35.1)

Live in own residence
No 1,574 (61.1) 152 (58.0)
Yes 1,000 (38.9) 110 (42.0)

White and other 260 (10.1) 28 (10.7)
Black 2,314 (89.9) 234 (89.3)

No 2,366 (91.9) 236 (90.1)
Yes 198 (7.7) 22 (8.4)

Frequency of drug use
Less than 1 per week 414 (16.1) 45 (17.2)
1–6 times per week 891 (34.6) 81 (30.9)
Once a day 1,003 (39.0) 108 (41.2)
More than once a day 266 (10.3) 28 (10.7)

BNEP use
Low 770 (29.9) 81 (30.9)
Medium 941 (36.6) 98 (37.4)
High 863 (33.5) 83 (31.7)

Syringe relayers 800 (31.1) 73 (27.9)
Average days circulation (SD) 29.4 (25.1) 27.9 (23.1)

“All participants” are Baltimore Needle Exchange Program (BNEP)
participants at registration who visited more than once and returned
at least one program syringe; and for the evaluation subsample were
periodically tested for HIV, were seronegative on enrollment, and re-
turned at least one program syringe.

syringes were not returned.) The average number of days from the first to last visit
was 315 (SD = 254). Of the 2,574 participants, roughly a third were classified into
each use category, with 29.9% low users, 36.5% medium users, and 33.6% classi-
fied as high users.

Table 2 reports associations between BNEP use and demographic characteris-
tics. BNEP use was not associated with gender, cohabitation status, residential sta-
tus, or race. For example, 71.3% of low users and 70.8% of high users were male.
Age, however, was significantly different among groups: Low users were younger
than medium or high users. Employment and drug use frequency were also signifi-


TABLE 2. Baltimore Needle Exchange Program utilization status
by demographic, drug use frequency, syringe relay, and syringe
circulation time

Low Medium High

All participants (N = 2,574)
Total 770 (29.9) 941 (36.6) 863 (33.5)
Female, % 28.7 26.3 29.2
Average age,* years 40.4 41.1 43.0
Cohabit, % 32.7 29.8 30.9
Live in own residence, % 37.7 37.6 41.2
African American, % 88.5 90.2 90.8
Employed,† % 9.3 8.2 5.8
Average drug use frequency† 2.12 2.18 2.24
Syringe relayers,* % 60.2 31.9 4.2
Syringe circulation time,* days 31.2 30.3 26.8

Evaluation subsample (N = 262)
Total 81 (30.9) 98 (37.4) 83 (31.7)
Female, % 24.7 32.7 41.0
Average age, years 40.4 40.8 41.5
Cohabit, % 37.0 34.7 33.7
Live in own residence, % 40.7 39.8 45.8
African American, % 84.0 91.8 91.6
Employed, % 9.1 11.2 4.8
Average drug use frequency 2.17 2.17 2.23
Syringe relayers,* % 59.2 23.5 2.4
Syringe circulation time, days 27.8 31.1 24.3

*P < .001.
†P < .05.

cantly different among groups, with high users reporting more frequent drug use
and lower employment rates than medium or low users.

Syringe relay was significantly different among groups: 60.2% of low BNEP
users were syringe relayers, while only 4.2% of high BNEP users were syringe relay-
ers (P < .001). Circulation time was significantly different, but modest, among
groups: The needles of low BNEP users circulated an average of 31.2 days, while
those of high BNEP users circulated an average of 26.8 days (P < .001). Thus, low
users were more likely to return syringes originally distributed to someone else, and
those syringes circulated in the community about 4 days (14%) longer.

Results for the evaluation subsample were similar to those of the larger sample,
but some relationships previously statistically significant were not statistically sig-
nificant (perhaps due to the smaller sample size). For example, high users had an
average older age, but the difference was not statistically significant. Bivariate dif-
ferences were also statistically insignificant for employment, drug use frequency,
and circulation times. Syringe relay remained statistically significantly associated
with BNEP use for the evaluation subsample, with 59.2% of low users being sy-
ringe relayers compared to only 2.4% of high users.

Table 3 reports a multivariate analysis of BNEP use (standardized average of


TABLE 3. Standardized multivariate regression
coefficients for Baltimore Needle Exchange Program use

All participants subsample

(N = 2,574) (N = 262)

Female −.01 .06
Age categorized .09* .09
Cohabitation −.01 −.01
Live in own residence .02 .10
African American .02 .02
Employment −.02 .01
Drug use frequency .05† .07
Duration in study NA .27*
Syringe relayer −.31* −.38*
Syringe circulation time −.04*‡ −.02
Adjusted R2 12% 25%

NA, not applicable.
*P < .001.
†P < .01.
‡P < .05.

the BNEP use variables)* predicted by gender, age, cohabitation status, residence
status, race, employment, drug use frequency, syringe relay, and circulation time.
The results are consistent with the bivariate analysis in that age, reported drug use
frequency, syringe relay, and circulation time were significantly associated with
BNEP use. Participants who were older and more frequent drug users were higher
users of the BNEP. In addition, participants who returned their own syringes and
who returned them more quickly used the BNEP more.

The evaluation subsample multivariate regression produced similar results, but
the associations between BNEP use and age and drug use frequency again were not
statistically significant. Duration in study was significantly associated with BNEP
use, which derives from the fact that both duration and BNEP use are measured,
in part, by how long the participant had been in contact with the BNEP. Syringe
relay was also negatively associated with BNEP use in the evaluation subsample
(β = −.38, P < .001).

Table 4 analyzes the association between BNEP use and HIV seroconversion
for the tested subsample. None of the sociodemographic characteristics was associ-
ated with HIV seroconversion during the study period. Duration in the study was
significantly associated with HIV seroincidence (odds ratio [OR] = 2.06), indicating
that participants who seroconverted were more than two times as likely to do it in
later tests rather than earlier ones, as expected. BNEP use was not associated with
seroconversion, nor was circulation time, indicating that more BNEP use and more
rapid return of syringes did not directly lower the individual likelihood of becoming
HIV positive. The odds ratio for HIV seroconversion and syringe relay was 2.73,
indicating that participants who returned syringes originally acquired by someone

*BNEP use was created by standardizing the variables volume, frequency, and duration to have a mean
of 0 and a standard deviation of 1 (converted to z scores). We then calculated the average of the three
standardized variables to obtain BNEP use that had a mean of 0 and a standard deviation of 0.85.


TABLE 4. Bivariate logistic regression for likelihood
of seroconversion (N = 262)

Odds 95% Confidence
Characteristics ratio interval

Female 1.49 0.46–4.84
Age categorized 1.06 0.88–1.19
Cohabit 1.34 0.41–4.34
Live in own residence 0.99 0.30–3.19
Frequency of drug use 1.64 0.68–3.98
Duration in study 2.06 1.24–3.42
BNEP use 1.18 0.65–2.15
Syringe relayer 2.73 0.85–8.76
Circulation time 0.98 0.93–1.02

BNEP, Baltimore Needle Exchange Program.

else were 2.73 times as likely to seroconvert during the course of the study (the
confidence intervals for syringe relay included one thus not significant at the 95%
level, but excluded one thus significant at the 90% level) than those who returned
their own syringes. As we see below, however, this marginal significant risk is mis-
leading since the risk occurs predominantly for women.

In the multivariate model that includes sex, duration in study, and syringe re-
lay, we found that both duration in the study and syringe relay were significantly
associated with HIV seroconversion. The sex and syringe relay variables interacted
with one another. Table 5 reports multivariate analysis of HIV seroconversion on
duration in study and the four interaction terms constructed from sex and syringe
relay. There was no difference in seroconversion for relay males compared to non-
relay males and no difference in seroconversion for nonrelay females compared to
nonrelay males. There was a significant difference in seroconversion among relay
females compared to nonrelay males (Table 5, adjusted OR = 8.53). Indeed, sero-
conversion for relay females compared to relay males was significantly higher (OR =
7.96, 95% CI = 1.18–53.69). Thus, the only risk for seroconversion was among
women who relayed syringes. This finding merits discussion.


The IDUs who used the BNEP more (defined as a composite of frequency, volume,
and duration) returned syringes somewhat more quickly and returned syringes

TABLE 5. Multivariate logistic regression for likelihood
of seroconversion

Adjusted 95% Confidence
Characteristics odds ratio interval

Duration in study 2.45 1.36–4.42
Male, no relay (reference) 1.00 —
Male, relay 1.07 0.19–6.00
Female, no relay 0.36 0.04–3.22
Female, relay 8.53 1.83–39.79


much more often if they personally had acquired them originally at the BNEP. This
suggests that the exclusive users of the BNEP are likely to benefit directly from
their contact with it.

Few of the evaluation subsample participants became HIV infected (n = 12);
hence, our data regarding HIV seroconversion are only suggestive. We found that
BNEP use was not significantly associated with a decrease in the likelihood of be-
coming seropositive. Syringe relay, however, was associated with becoming HIV
positive for women only. That is, women BNEP participants who returned syringes
to the BNEP that were originally acquired by someone else were more likely to
become HIV infected than those who returned their own syringes. Hence, BNEP
use provided the best protective effect for those who use the exchange exclusively
to obtain and return their own syringes. Perhaps this is due to the fact that women
syringe nonrelayers are using syringes exclusively themselves or within small, closed
drug-using networks and are at less risk for contracting HIV. Women relayers may
be returning syringes they used after a male partner had acquired them from some-
one else or somewhere else.

While the ideal for a NEP might be to promote purely exclusive use, it is recog-
nized programmatically that more people can be served by permitting secondary
and satellite exchange. According to Kaplan’s circulation theory,17 wider syringe
distribution should decrease circulation time and therefore decrease HIV risk at a
population level. However pragmatic, there must be caution in permitting second-
ary and satellite exchange as these activities result in IDUs getting clean needles,
but not HIV prevention services; thus, they may be as likely as before to share or
trade needles.

Conclusions cannot be drawn about the impact of secondary and satellite ex-
change on HIV transmission since this analysis was performed using data from a
NEP, and there was no means to bar code and collect needles from circumstances
outside the NEP. Thus, the results of this study in no way undermine or contradict
Kaplan’s circulation theory.17 Rather, the results suggest that exclusive users (de-
fined as persons returning their own syringes) have a lower risk of seroconversion
when compared to NEP users who return syringes initially issued to someone else.
Therefore, efforts to encourage exclusive use are prudent from a public health per-

Importantly, syringe relay was a risk factor only for women. Women who en-
gaged in syringe relay were more likely to seroconvert during the study than their
nonrelaying peers, but men were not. This indicates that women who return sy-
ringes acquired by others may be putting themselves at increased risk by not re-
stricting their drug use to themselves or small closed networks. Other research has
shown that women IDUs who share syringes with sexual partners may be at greater
risk for HIV infection, and this may be one of the factors driving the association
seen here.18 Future research is needed to investigate reasons why the HIV risk is so
much higher among women who relay syringes than among men who do.


This research was supported by the National Institute on Drug Abuse (DA09225
and DA10172). We thank Ronald Brookmeyer, Jacquie Astemborski, Peter Beilen-
son, and an anonymous reviewer for advice and Melissa Marx, Elise Riley, Steve
Huettner, Michele Brown, and the staff at the NEP who have worked diligently to
reduce HIV infection in this population.



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The program Evaluation Assignments will focus on ethical and/or practical concerns as well as provide examples of program evaluation research.

Address the following (PART 1): What is the NEP/SEP research (Valente, 2001; Kerr et al., 2010) examining specifically-include mention of any key concepts and the key variables (independent and dependent).

What data was used, how were the participants chosen, key findings and recommendations?

Note that syringe sharing is the common topic here. By the Program Evaluation Assignment 3 due date, submit a one-page document (single-spaced, 1” margins) that first clearly and concisely summarizes the above information along with the key findings of the study, and then (PART 2) include a discussion regarding how the behavior of the target population (as well as how target populations are defined program/politically) can impact program evaluation in general and for these particular studies; and how it can impact 1) perceptions of the NEP/SEP and 2)

how the success of such programs are assessed (think bias). Be specific.  You should also include (in general) how perceptions of the target population (did you define what is meant by this term), and how it can bias program evaluations (how they are designed and conducted, particularly of programs that serve target populations that have been negatively portrayed by politicians (and their surrogates).   
Schneider and Ingram and the other supplemental readings should be integrated into this part but not just summaries–integrate the ideas or use for examples. 
 This latter part should be 40-50% of the paper. So, the two parts should be about an equal length. Be sure to follow APA and writing academic paper guidelines.  IMPORTANT: These are not original research papers so DO NOT follow that format–you are learning to do a clear and concise summary of the research including the important points of that research.

Draw on the provided articles but feel free to draw on another academic research as well.

Valente, T. W. (2001). Needle-exchange participation, effectiveness, and policy: syringe relay, gender, and the paradox of public health. Journal of Urban Health: Bulletin of the New York Academy of Medicine78(2), 340–349. 

Kerr, T., Small, W., Buchner, C., Zhang, R., Li, K., Montaner, J., & Wood, E. (2010). Syringe Sharing and HIV Incidence Among Injection Drug Users and Increased Access to Sterile Syringes. American Journal of Public Health100(8), 1449–1453.

Required Supplemental Readings

Lewis, D. C., Flores, A. R., Haider-Markel, D. P., Miller, P. R., Tadlock, B. L., & Taylor, J. K. (2017). Degrees of Acceptance: Variation in Public Attitudes toward Segments of the LGBT Community. Political Research Quarterly70(4), 861–875. 

Miller, L. R., & Grollman, E. A. (2015). The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health. Sociological Forum30(3), 809–831.

Schneider, A., & Ingram, H. (1993). Social Construction of Target Populations: Implications for Politics and Policy. American Political Science Review87(2), 334–347. 

IMPORTANT: Do not provide any commentary about the program, personal background information, etc. Just address what is asked for. 

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