In this mixed-methods study, we examine the relationship between provider communication and patie... more In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women’s Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers’ expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient–provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.
Sex and sexuality are important determinants of health and wellbeing across the life course. The ... more Sex and sexuality are important determinants of health and wellbeing across the life course. The desire and capacity for sexual intimacy and pleasure among older adults are neglected areas of research due to ageist assumptions that they no longer engage in sexual activity. These assumptions are most pronounced in HIV research, where we aggressively studied intimate details of sexual behaviors of people living with HIV until they became “old.” Interest in the sexual behaviors among older adults with HIV has waned in HIV prevention, suggesting an inherent ageism within the field. We will discuss emerging new HIV and STI risks for older adults, declining trends in gerosexuality funding, HIV media campaigns targeted for older adults, and new evidence that suggest that interventions that engage older adults with HIV in conversations about sexual health, menopause, and erectile dysfunction may be an effective strategy for promoting overall successful aging
Causal inference methods can be applied to estimate the effect of a point exposure or treatment o... more Causal inference methods can be applied to estimate the effect of a point exposure or treatment on an outcome of interest using data from observational studies. When the outcome of interest is a count, the estimand is often the causal mean ratio, i.e., the ratio of the counterfactual mean count under exposure to the counterfactual mean count under no exposure. This paper considers estimators of the causal mean ratio based on inverse probability of treatment weights, the parametric g-formula, and doubly robust estimation, each of which can account for overdispersion, zero-inflation, and heaping in the measured outcome. Methods are compared in simulations and are applied to data from the Women's Interagency HIV Study to estimate the effect of incarceration in the past six months on two count outcomes in the subsequent six months: the number of sexual partners and the number of cigarettes smoked per day.
Our previous quantitative research found high prevalence of self-rated successful aging (SA) amon... more Our previous quantitative research found high prevalence of self-rated successful aging (SA) among older (age ≥50) women living with HIV (OWLH) enrolled in the Women’s Interagency HIV Study (WIHS). However, little is known about how OWLH define SA. Most studies have examined SA among predominantly white men living with HIV. Therefore, the purpose of our qualitative study was to examine subjective understandings of SA among OWLH and, as a comparison group, older HIV-seronegative women at risk of HIV. Four focus group discussions (FGD) were conducted among 23 participants (12 OWLH, 11 HIV-seronegative). These women were recruited from WIHS participants previously enrolled in our quantitative study of SA, “From Surviving to Thriving” (FROST), at two WIHS sites – Atlanta and Brooklyn. At each site, we conducted two FGD – one with OWLH and one with older HIV-seronegative women in February-March of 2019. Participants were, on average, 56 years old (range, 51-70), 78% Black, and 60% with a...
In the United States (U.S.), people aged 55 years and older make up 36% of people living with HIV... more In the United States (U.S.), people aged 55 years and older make up 36% of people living with HIV/AIDS (PLWHA). Nearly 20% of new HIV infections occur among people aged 50+. While medical breakthroughs in HIV treatment have allowed PLWHA to live longer, healthier lives, structural conditions still exist that affect health outcomes of older adults living with HIV/AIDS (OALWHA). These conditions continue to disproportionately burden OALWHA, particularly older adults of color. Therefore, a greater understanding of the social determinates of health (SDH) is essential to continue making progress in HIV treatment, maintenance, and prevention. The U.S. Centers for Disease Control and Prevention (CDC) has highlighted several SDH among OALWHA, including: poverty, education, income, employment status, health insurance coverage, and housing. This symposium will highlight emerging research that examines several of these indicators among OALWHA. Using a variety of research methodologies, the fiv...
The COVID-19 pandemic in NYC, the epicenter of the US crisis, revealed indisputable evidence that... more The COVID-19 pandemic in NYC, the epicenter of the US crisis, revealed indisputable evidence that social determinants of health (SDoH, e.g., racism, crowded housing, employment risks) and disparities in comorbid health risk factors produce higher burdens of disease and death among racial and ethnic populations. We conducted a needs assessment of SDoH among 1400 patients in several ambulatory care clinics to explore the impact among older adults, across different clinical populations. Among older adults with HIV (OAH), we found lower rates of food and housing insecurity compared to older adults without HIV. Despite higher levels of COVID knowledge and prevention adherence, we also found significantly higher levels of isolation, loneliness, depressive symptoms, and anxiety among OAHs compared to those without HIV. Access to Ryan White entitlements did buffer some impacts but preexisting high burdens of mental health issues were exacerbated, perhaps due to heightened perceptions of inc...
Successful aging (SA) is the capacity of older people to thrive despite age-related changes and/o... more Successful aging (SA) is the capacity of older people to thrive despite age-related changes and/or declines. Although our previous research found that older (age ≥50) women living with HIV (OWLH) can achieve SA, considerable barriers remain. The purpose of this qualitative study was to identify specific barriers to SA among OWLH. Our sample consisted of 29 OWLH recruited between October 2018 and March 2019 at two sites of Women’s Interagency HIV Study (WIHS): Atlanta, GA and Brooklyn, NY. These participants were assigned to either semi-structured interviews (N=17: 8 interviews in Brooklyn and 9 in Atlanta) or focus group discussions (FGD: 1 FGD in Atlanta with 5 participants, and 1 FGD in Brooklyn with 7 participants). Our FGD and Interview Guides included questions focused on barriers to SA. Participants were, on average, 58 years old (range 50-73), 86% Black, 83% single, and 62% with annual income ≤ $12,000. All interviews and FGD were transcribed and coded using MAXQDA software. ...
I have had the pleasure of serving as Co-Convener of the HIV, AIDS and Older Adults Special Inter... more I have had the pleasure of serving as Co-Convener of the HIV, AIDS and Older Adults Special Interest Group (SIG) for seven years (2013 to now). During this time, we witnessed an increase in NIH funding opportunities, most notable was the Multidisciplinary Studies in HIV/AIDS and Aging FOA. NIH also renewed its support for two prominent longitudinal HIV cohort studies (now knowns as the Combined Cohort Study) because of their unmatched ability to provide insight on the effects of HIV infection and aging. Individuals older than 50 years of age are now included in AIDS and HIV prevention clinical trials. And, in 2008 the AIDS Institute launched the first National HIV/AIDS and Aging Awareness Day (Sept 18th). During this period, the SIG continued to raise awareness about HIV and aging through sponsored symposia and Webinars, and participants for the SIG participated in the first HIV and aging GSA Momentum Discussion. Part of a symposium sponsored by the HIV, AIDS and Older Adults Intere...
Journal of health disparities research and practice, 2014
To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops l... more To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops located in high HIV seroprevalent neighborhoods of Brooklyn, NY. Data on HIV-risk related behaviors and other characteristics were collected from barbershop clients. All participants (n=60) completed brief risk assessments; and a subset (n=22) also completed focus groups and/or individual interviews. Of the subset of 22 men, 68% were US born, 59% had been in jail/prison, 32% were unemployed; and during the 3 months before the interviews, 68% reported at least two partners and 45% reported unprotected vaginal or anal sex with two or more women. Emergent themes included: 1) the psychological function of multiple partnerships; 2) calculated risk taking regarding condom use; 3) the role of emotional attachment and partner trust in condom use; 4) low perceived HIV risk and community awareness; and 5) lack of relationship between HIV testing and safer sex practices. Interventions among heterose...
Background Age-related non-AIDS comorbidities (NACM) increasingly account for morbidity and morta... more Background Age-related non-AIDS comorbidities (NACM) increasingly account for morbidity and mortality in persons living with HIV. The burden of NACM and its association with HIV is poorly described in women. Methods We analyzed data from HIV+ and at-risk HIV− participants who were followed in the Women’s Interagency HIV Study (WIHS) after 2009 (when >80% of participants used antiretroviral therapy). The prevalence of each NACM (defined by a combination of self-report, clinical measurements, and laboratory data) and the number of NACM were summarized at a most recent follow-up visit and were compared by age and HIV serostatus using unadjusted linear regression models. Results There were 3232 women (2309 HIV+, 923 HIV–) with a median follow-up of 15.3 years. The median age was 50 years, 65% were black, 38% currently smoked, 71% had ever used illicit drugs, 50% had annual income < $12,000, and median body mass index was 30 kg/m2. HIV+ women had a median CD4 count of 618 cells/mm3...
To investigate medical decision-making from the thoracic surgeons' and patients' perspect... more To investigate medical decision-making from the thoracic surgeons' and patients' perspectives in early-stage lung cancer. We conducted one focus group with thoracic surgeons (n = 15) and one with a group of early-stage lung cancer patients treated with surgery (n = 7). Focus groups were recorded, transcribed and coded for themes. For surgeons, surgical procedure choice was a primary concern, followed by the surgical treatment plan decision-making process. Survivors focused primarily on the physical and mental health-related postsurgical burden for which they felt they were not well prepared and placed less emphasis on surgical decision-making. As early-stage lung cancer mortality rates are improving, surgeons and patients can prioritize surgical approaches and postsurgical care that enhance quality of life.
Sexual violence is associated with increased risk of HIV acquisition/transmission in women. Force... more Sexual violence is associated with increased risk of HIV acquisition/transmission in women. Forced sex can result in physical trauma to the reproductive tract as well as severe psychological distress. However, immuno-biological mechanisms linking sexual violence and HIV susceptibility are incompletely understood. Using the Women's Interagency HIV Study repository, a total of 77 women were selected to form 4 groups, stratified by HIV serostatus, in the following categories: 1) no sexual abuse history and low depressive symptom score (below clinically significant cut-off, scores <16) (Control); 2) no sexual abuse history but high depressive symptom score, ≥16 (Depression); 3) chronic sexual abuse exposure and low depressive symptom score (Abuse); 4) chronic sexual abuse exposure and high depressive symptom score (Abuse+Depression). Inflammation-associated cytokines/chemokines/proteases (TNF-α, IL-6, IL-1α, IL-1β, TGF-β MIP-3α, IP-10, MCP-1, Cathepsin B), anti-inflammatory/anti-...
Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential ... more Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial...
There is limited research examining the sexual health and well-being of older women living with H... more There is limited research examining the sexual health and well-being of older women living with HIV (OWLH). Most studies focus on sexual dysfunction, leaving aside the richer context of sexuality and sexual health, including the effect of age-related psychosocial and interpersonal changes on sexual health behaviors. Guided by the integrative biopsychosocial model and the sexual health model, this study explored the importance of sex and sexuality among OWLH to identify their sexual health and HIV prevention needs for program planning. A purposive sample (n = 50) of OWLH was selected from a parent study (n = 2052). We conducted 8 focus groups and 41 in-depth interviews with 50 African American and Latina OWLH aged 50-69 years old in three U.S. cities. The triangulation approach was used to synthesize the data. Six salient themes emerged: sexual pleasure changes due to age, sexual freedom as women age, the role of relationships in sexual pleasure, changes in sexual ability and sexual ...
In this mixed-methods study, we examine the relationship between provider communication and patie... more In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women’s Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers’ expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient–provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.
Sex and sexuality are important determinants of health and wellbeing across the life course. The ... more Sex and sexuality are important determinants of health and wellbeing across the life course. The desire and capacity for sexual intimacy and pleasure among older adults are neglected areas of research due to ageist assumptions that they no longer engage in sexual activity. These assumptions are most pronounced in HIV research, where we aggressively studied intimate details of sexual behaviors of people living with HIV until they became “old.” Interest in the sexual behaviors among older adults with HIV has waned in HIV prevention, suggesting an inherent ageism within the field. We will discuss emerging new HIV and STI risks for older adults, declining trends in gerosexuality funding, HIV media campaigns targeted for older adults, and new evidence that suggest that interventions that engage older adults with HIV in conversations about sexual health, menopause, and erectile dysfunction may be an effective strategy for promoting overall successful aging
Causal inference methods can be applied to estimate the effect of a point exposure or treatment o... more Causal inference methods can be applied to estimate the effect of a point exposure or treatment on an outcome of interest using data from observational studies. When the outcome of interest is a count, the estimand is often the causal mean ratio, i.e., the ratio of the counterfactual mean count under exposure to the counterfactual mean count under no exposure. This paper considers estimators of the causal mean ratio based on inverse probability of treatment weights, the parametric g-formula, and doubly robust estimation, each of which can account for overdispersion, zero-inflation, and heaping in the measured outcome. Methods are compared in simulations and are applied to data from the Women's Interagency HIV Study to estimate the effect of incarceration in the past six months on two count outcomes in the subsequent six months: the number of sexual partners and the number of cigarettes smoked per day.
Our previous quantitative research found high prevalence of self-rated successful aging (SA) amon... more Our previous quantitative research found high prevalence of self-rated successful aging (SA) among older (age ≥50) women living with HIV (OWLH) enrolled in the Women’s Interagency HIV Study (WIHS). However, little is known about how OWLH define SA. Most studies have examined SA among predominantly white men living with HIV. Therefore, the purpose of our qualitative study was to examine subjective understandings of SA among OWLH and, as a comparison group, older HIV-seronegative women at risk of HIV. Four focus group discussions (FGD) were conducted among 23 participants (12 OWLH, 11 HIV-seronegative). These women were recruited from WIHS participants previously enrolled in our quantitative study of SA, “From Surviving to Thriving” (FROST), at two WIHS sites – Atlanta and Brooklyn. At each site, we conducted two FGD – one with OWLH and one with older HIV-seronegative women in February-March of 2019. Participants were, on average, 56 years old (range, 51-70), 78% Black, and 60% with a...
In the United States (U.S.), people aged 55 years and older make up 36% of people living with HIV... more In the United States (U.S.), people aged 55 years and older make up 36% of people living with HIV/AIDS (PLWHA). Nearly 20% of new HIV infections occur among people aged 50+. While medical breakthroughs in HIV treatment have allowed PLWHA to live longer, healthier lives, structural conditions still exist that affect health outcomes of older adults living with HIV/AIDS (OALWHA). These conditions continue to disproportionately burden OALWHA, particularly older adults of color. Therefore, a greater understanding of the social determinates of health (SDH) is essential to continue making progress in HIV treatment, maintenance, and prevention. The U.S. Centers for Disease Control and Prevention (CDC) has highlighted several SDH among OALWHA, including: poverty, education, income, employment status, health insurance coverage, and housing. This symposium will highlight emerging research that examines several of these indicators among OALWHA. Using a variety of research methodologies, the fiv...
The COVID-19 pandemic in NYC, the epicenter of the US crisis, revealed indisputable evidence that... more The COVID-19 pandemic in NYC, the epicenter of the US crisis, revealed indisputable evidence that social determinants of health (SDoH, e.g., racism, crowded housing, employment risks) and disparities in comorbid health risk factors produce higher burdens of disease and death among racial and ethnic populations. We conducted a needs assessment of SDoH among 1400 patients in several ambulatory care clinics to explore the impact among older adults, across different clinical populations. Among older adults with HIV (OAH), we found lower rates of food and housing insecurity compared to older adults without HIV. Despite higher levels of COVID knowledge and prevention adherence, we also found significantly higher levels of isolation, loneliness, depressive symptoms, and anxiety among OAHs compared to those without HIV. Access to Ryan White entitlements did buffer some impacts but preexisting high burdens of mental health issues were exacerbated, perhaps due to heightened perceptions of inc...
Successful aging (SA) is the capacity of older people to thrive despite age-related changes and/o... more Successful aging (SA) is the capacity of older people to thrive despite age-related changes and/or declines. Although our previous research found that older (age ≥50) women living with HIV (OWLH) can achieve SA, considerable barriers remain. The purpose of this qualitative study was to identify specific barriers to SA among OWLH. Our sample consisted of 29 OWLH recruited between October 2018 and March 2019 at two sites of Women’s Interagency HIV Study (WIHS): Atlanta, GA and Brooklyn, NY. These participants were assigned to either semi-structured interviews (N=17: 8 interviews in Brooklyn and 9 in Atlanta) or focus group discussions (FGD: 1 FGD in Atlanta with 5 participants, and 1 FGD in Brooklyn with 7 participants). Our FGD and Interview Guides included questions focused on barriers to SA. Participants were, on average, 58 years old (range 50-73), 86% Black, 83% single, and 62% with annual income ≤ $12,000. All interviews and FGD were transcribed and coded using MAXQDA software. ...
I have had the pleasure of serving as Co-Convener of the HIV, AIDS and Older Adults Special Inter... more I have had the pleasure of serving as Co-Convener of the HIV, AIDS and Older Adults Special Interest Group (SIG) for seven years (2013 to now). During this time, we witnessed an increase in NIH funding opportunities, most notable was the Multidisciplinary Studies in HIV/AIDS and Aging FOA. NIH also renewed its support for two prominent longitudinal HIV cohort studies (now knowns as the Combined Cohort Study) because of their unmatched ability to provide insight on the effects of HIV infection and aging. Individuals older than 50 years of age are now included in AIDS and HIV prevention clinical trials. And, in 2008 the AIDS Institute launched the first National HIV/AIDS and Aging Awareness Day (Sept 18th). During this period, the SIG continued to raise awareness about HIV and aging through sponsored symposia and Webinars, and participants for the SIG participated in the first HIV and aging GSA Momentum Discussion. Part of a symposium sponsored by the HIV, AIDS and Older Adults Intere...
Journal of health disparities research and practice, 2014
To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops l... more To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops located in high HIV seroprevalent neighborhoods of Brooklyn, NY. Data on HIV-risk related behaviors and other characteristics were collected from barbershop clients. All participants (n=60) completed brief risk assessments; and a subset (n=22) also completed focus groups and/or individual interviews. Of the subset of 22 men, 68% were US born, 59% had been in jail/prison, 32% were unemployed; and during the 3 months before the interviews, 68% reported at least two partners and 45% reported unprotected vaginal or anal sex with two or more women. Emergent themes included: 1) the psychological function of multiple partnerships; 2) calculated risk taking regarding condom use; 3) the role of emotional attachment and partner trust in condom use; 4) low perceived HIV risk and community awareness; and 5) lack of relationship between HIV testing and safer sex practices. Interventions among heterose...
Background Age-related non-AIDS comorbidities (NACM) increasingly account for morbidity and morta... more Background Age-related non-AIDS comorbidities (NACM) increasingly account for morbidity and mortality in persons living with HIV. The burden of NACM and its association with HIV is poorly described in women. Methods We analyzed data from HIV+ and at-risk HIV− participants who were followed in the Women’s Interagency HIV Study (WIHS) after 2009 (when >80% of participants used antiretroviral therapy). The prevalence of each NACM (defined by a combination of self-report, clinical measurements, and laboratory data) and the number of NACM were summarized at a most recent follow-up visit and were compared by age and HIV serostatus using unadjusted linear regression models. Results There were 3232 women (2309 HIV+, 923 HIV–) with a median follow-up of 15.3 years. The median age was 50 years, 65% were black, 38% currently smoked, 71% had ever used illicit drugs, 50% had annual income < $12,000, and median body mass index was 30 kg/m2. HIV+ women had a median CD4 count of 618 cells/mm3...
To investigate medical decision-making from the thoracic surgeons' and patients' perspect... more To investigate medical decision-making from the thoracic surgeons' and patients' perspectives in early-stage lung cancer. We conducted one focus group with thoracic surgeons (n = 15) and one with a group of early-stage lung cancer patients treated with surgery (n = 7). Focus groups were recorded, transcribed and coded for themes. For surgeons, surgical procedure choice was a primary concern, followed by the surgical treatment plan decision-making process. Survivors focused primarily on the physical and mental health-related postsurgical burden for which they felt they were not well prepared and placed less emphasis on surgical decision-making. As early-stage lung cancer mortality rates are improving, surgeons and patients can prioritize surgical approaches and postsurgical care that enhance quality of life.
Sexual violence is associated with increased risk of HIV acquisition/transmission in women. Force... more Sexual violence is associated with increased risk of HIV acquisition/transmission in women. Forced sex can result in physical trauma to the reproductive tract as well as severe psychological distress. However, immuno-biological mechanisms linking sexual violence and HIV susceptibility are incompletely understood. Using the Women's Interagency HIV Study repository, a total of 77 women were selected to form 4 groups, stratified by HIV serostatus, in the following categories: 1) no sexual abuse history and low depressive symptom score (below clinically significant cut-off, scores <16) (Control); 2) no sexual abuse history but high depressive symptom score, ≥16 (Depression); 3) chronic sexual abuse exposure and low depressive symptom score (Abuse); 4) chronic sexual abuse exposure and high depressive symptom score (Abuse+Depression). Inflammation-associated cytokines/chemokines/proteases (TNF-α, IL-6, IL-1α, IL-1β, TGF-β MIP-3α, IP-10, MCP-1, Cathepsin B), anti-inflammatory/anti-...
Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential ... more Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial...
There is limited research examining the sexual health and well-being of older women living with H... more There is limited research examining the sexual health and well-being of older women living with HIV (OWLH). Most studies focus on sexual dysfunction, leaving aside the richer context of sexuality and sexual health, including the effect of age-related psychosocial and interpersonal changes on sexual health behaviors. Guided by the integrative biopsychosocial model and the sexual health model, this study explored the importance of sex and sexuality among OWLH to identify their sexual health and HIV prevention needs for program planning. A purposive sample (n = 50) of OWLH was selected from a parent study (n = 2052). We conducted 8 focus groups and 41 in-depth interviews with 50 African American and Latina OWLH aged 50-69 years old in three U.S. cities. The triangulation approach was used to synthesize the data. Six salient themes emerged: sexual pleasure changes due to age, sexual freedom as women age, the role of relationships in sexual pleasure, changes in sexual ability and sexual ...
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