Bisexual Populations Research Articles

Mathematical Model of HIV/AIDS Considering Sexual Preferences Under Antiretroviral Therapy, a Case Study in San Juan de Pasto, Colombia.

While several studies on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in the homosexual and heterosexual population have demonstrated substantial advantages in controlling HIV transmission in these groups, the overall 2benefits of the models with a bisexual population and initiation of antiretroviral therapy have not had enough attention in dynamic modeling. Thus, we used a mathematical model based on studying the impacts of bisexual behavior in a global community developed in the PhD thesis work of Espitia (2021). The model is governed by a nonlinear ordinary differential equation system, the parameters of which are calibrated with data from the cumulative cases of HIV infection and AIDS reported in San Juan de Pasto in 2019. Our model estimations show which parameters are the most influential and how to modulate them to decrease the HIV infection.

ON ONE OF THE FAMILY OF EVOLUTION OPERATORS

In this paper we study dynamical systems generated by a gonosomal evolution operator of a bisexual population. We find explicitly all (uncountable set) of fixed points of the operator. It is shown that each fixed point has eigenvalues less or equal to 1. Moreover, we show that each trajectory converges to a fixed point, i.e. the operator is reqular. There are uncountable family of invariant sets each of which consisting unique fixed point. Thus there is one-to-one correspondence between such invariant sets and the set of fixed points. Any trajectory started at a point of the invariant set converges to the corresponding fixed point.

Gambling, Gaming, and Internet Behavior in a Sexual Minority Perspective. A Cross-Sectional Study in Seven European Countries.

BackgroundAddictive behavior of gambling, gaming and internet activity is partly a new research domain and has not been well investigated with regard to sexual minority populations. Although health disparities between sexual minorities and the general population are well documented, there is a lack of inclusion of sexual minorities in both research and clinic. Among lesbian, gay and bisexual populations certain features could be present that play a role for the development of addictive behaviors, such as social isolation and increased risk of other psychiatric problems. The aim of this study was to investigate problem gambling, problem gaming and problematic internet behavior in a European context and if it is affected by sexual orientation status.MethodsAn online web-survey was distributed among web-panels in England, Poland, Switzerland, Italy, Spain, Denmark, and Sweden in 2017–2018.Result10 983 complete answers were collected. 7.1% of the participants had a sexual minority status (n = 774). Regression models found that there was no difference in gambling, gaming and internet behavior among heterosexual and sexual minority men. Sexual minority women were associated with problematic gambling and gaming behavior, when also controlling for age and nationality. When also controlling for psychological distress, women defining as having another sexual minority status than lesbian and bisexual remained significant for having a problematic gaming behavior (AOR = 2.3).ConclusionAn awareness of female sexual minority perspectives is relevant in facilities treating behavioral addiction as well as in future research in behavioral addiction. More research is needed in problematic gambling and gaming behavior in different sexual minority populations with regard to psychiatric comorbidity and living conditions. An inclusion of sexual minority groups defining as other than gay and bisexual is needed in future research. No significant differences were found between heterosexual and sexual minority men in adjusted analysis in this study.

Promoting Smoking Cessation Among Lesbian and Bisexual Women: Lessons Learned From a Location-Based Media Campaign in Western North Carolina.

Despite well-documented inequities in tobacco use for lesbian, gay, bisexual, and transgender populations, there is little practical guidance for local public health officials on developing and implementing media campaigns that prioritize lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. In this practice note article, we describe the development and lessons learned from a location-based media campaign to promote tobacco use cessation and raise awareness of QuitlineNC among lesbian and bisexual women in Western North Carolina. The campaign used a digital approach based on cell phone locations and marketing profiles to deliver messages across 4 years (2018-2021). Considerations for practitioners include how our project required messaging adaptation to meet Google's restrictions against using the word "yours" and the importance of addressing privacy protection concerns with state officials to enable collection of outcome evaluation measures via a conversion pixel (code for capturing metrics).

Mapping low-wage and precarious employment among lesbian, gay, bisexual, and transgender people in Organization for Economic Co-operation and Development countries: A scoping review protocol

Background: Low-wage and precarious employment are prevalent and on the rise, disproportionately impacting marginalized populations. Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations have been largely left out of economic justice movements and scholarly literature on precarious employment and its deleterious social and health impacts. Methods: This scoping review protocol will guide a theoretical and narrative mapping of the literature on low-wage and precarious employment among LGBTQ+ people to better understand the extent and nature of this phenomenon. We will include empirical literature that discuss dimensions of this phenomenon in Organisation and Economic Co-operation and Development countries published on/after January 1, 2000. PRISMA-ScR guidelines structure this protocol. We will search 10 bibliographic databases to locate literatures across disciplines: EconLit, Sociological Abstracts, Scopus, PsycInfo, Social Work Abstracts, ABI/Inform, Business Source Premier, LGBTQ+ Source, Gender Studies Database, and Web of Science, with support from a Public Health Research Librarian. A rigorous search strategy was developed for PsycInfo (OVID) and will be adapted for subsequent database searches. Titles and abstracts will be independently screened by a subset of co-authors, followed by a full text review. Data abstraction and charting will be conducted using a standardized abstraction tool.

The prevalence of hepatitis C and hepatitis B in lesbian, gay, bisexual and transgender populations: a systematic review and meta-analysis

ObjectivesThis study aimed to systematically review the literature on the prevalence of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in transgender and LGBT people and determine their pooled estimates worldwide.MethodsDatabases (PubMed, Scopus, Web of Science, Embase, Ovid, Cochrane, PsycInfo) were searched from April 2000 to July 2021. The analyses were executed using the random-effects model in Stata 16.ResultsTen studies, including eight studies on four transgender people and two studies on 2150 LGBTs, were included. The pooled prevalence of HCV and HBV in all transgender populations globally were 9% (95% CI 3–15%) and 11% (95% CI 2–20%), respectively. The corresponding prevalence in male-to-female transgender people were estimated as 5% (95% CI 1–9%) and 6% (95% CI 3–10%), respectively. These estimates in American transgenders were 10% (95% CI 5–25%) and 16% (95% CI 8–23%), respectively.ConclusionThis study was identified the overall prevalence of HBV and HCV infections in transgender people, which were higher than those in the general population.

Prevalence and Sociodemographic and Behavioral Correlates of Psychological Distress among Lesbian, Gay, and Bisexual Adults in the United States, 2013-2018

Background: The lesbian, gay, bisexual, and transgender (LGBT) population comprises approximately 5.6% of the total US population. Levels and patterns of psychological distress in the LGBT population are less well known compared with the general population. This study examines the prevalence and sociodemographic and behavioral correlates of psychological distress among lesbian, gay, and bisexual (LGB) adults in the United States. Methods: Using the pooled cross-sectional data from the 2013-2018 National Health Interview Surveys (N=183,020), differentials in serious psychological distress (SPD) and factor-based psychological distress scores were analyzed by multivariate linear and logistic regression. Results: The prevalence of SPD was 8.0% for the LGB population aged ≥18, 7.0% for gay and bisexual males, and 8.9% for LGB females, compared with 3.4% for the total straight/heterosexual population, 2.7% for straight males, and 4.0% for straight females. Mean psychological distress index scores were highest among LGB females (109.8), followed by gay and bisexual males (105.8), straight females (100.6), and straight males (97.7). Compared with the straight population, LGB adults had higher education, unemployment, and poverty levels and were more likely to be non-Hispanic White and single. LGB adults were more likely to smoke and drink alcohol and more likely to be physically active than straight adults. LGB females had higher obesity but gay and bisexual males had lower obesity rates than their straight counterparts. After controlling for covariates, LGB adults had 89% higher odds of SPD and significantly higher distress levels than straight adults. Younger age, lower-income, divorce/separation, lack of health insurance, functional limitation, smoking, physical inactivity, and obesity were significant predictors of SPD and higher psychological distress levels in LGB adults. Conclusion and Implications for Translation: Significant disparities in mental health exist, with LGB adults at substantially increased risk of psychological distress and likely in greater need of appropriate social and mental health services. Health policies aimed at improving the material conditions and social environments may lead to improved mental health outcomes among LGB adults and the general population. Copyright © 2022 Singh, et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Food Insecurity among Lesbian, Gay, Bisexual, and Transgender Adults During the COVID-19 Pandemic in the United States, July-October 2021

Background: The lesbian, gay, bisexual, and transgender (LGBT) population makes up approximately 6% of the total United States (US) population. Levels and patterns of food insecurity in the LGBT population during the COVID-19 pandemic compared with the general population are unknown. This study examines prevalence and sociodemographic correlates of food insecurity among LGBT and straight/heterosexual adults in the US. Methods: Using the US Census Bureau’s Household Pulse Survey from July to October 2021 (N=372,542), differentials in food insecurity according to LGBT status were analyzed by multivariate logistic regression. Results: The prevalence of food insecurity during the pandemic was 25.6% for transgender adults aged ≥18, significantly higher than that for lesbian/gay adults (11.6%), bisexual adults (13.5%), and straight/heterosexual adults (7.8%). Compared with the straight/heterosexual population, LGBT adults had lower education and income levels and higher unemployment and were more likely to be non-Hispanic White and single. Transgender adults were particularly disadvantaged with respect to socioeconomic status, job loss, and lack of health insurance. After controlling for socioeconomic and demographic covariates, lesbian/gay, bisexual, and transgender adults experienced, respectively, 36%, 35%, and 157% higher odds of food insecurity than straight/heterosexual adults. Black/African American, Hispanic, and mixed-race/ethnicity, lower education and income, lack of homeownership, divorce/separation, lack of health insurance, and recent job loss were significant predictors of food insecurity among LGBT adults. Inequalities in food insecurity by LGBT status were similar in large metropolitan areas. Conclusions and Implication for Translation: Significant disparities in food insecurity exist withLGBT adults, particularly transgender adults, at substantially increased risk of experiencing food insecurity, economic hardship, and social disadvantage during the pandemic and likely in greater need of social and public assistance. Health policies aimed at improving the social and material conditions may lead to improved food security and health outcomes among LGBT adults and the general US population. Copyright © 2022 Singh et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Barriers to COVID-19 Vaccine Uptake in the LGBTQIA Community.

Objectives. To report findings from qualitative research that describe sources of hesitancy and barriers to vaccine uptake among lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) populations. Methods. In March 2021, we conducted focus groups with members of the Los Angeles, California LGBTQIA community to identify barriers to becoming vaccinated. Semistructured interviews were conducted with 32 individuals in 5 focus groups. Thematic analysis was conducted to identify themes. Results. Historical and ongoing medical trauma, including misgendering, and perceived emotional violence emerged as significant barriers to LGBTQIA individuals becoming vaccinated. Fear of violence was found to be a major barrier among transgender individuals, whereas fear of an unwelcoming vaccination site was a barrier for seniors. Finally, surviving was a higher priority than becoming vaccinated. Conclusions. Participants reported vaccine hesitancy and barriers that are unique to the life experiences of LGBTQIA individuals; these include medical trauma, violence, stigma, and discrimination. Our findings highlight the need to include LGBTQIA leaders and trusted individuals in the development of vaccination education and the delivery of vaccination services. (Am J Public Health. 2022;112(3):405-407. https://doi.org/10.2105/AJPH.2021.306599).

Biogenic synthesis of gold nanoparticles using Artemia urumiana extract and five different thermal accelerated techniques: fabrication and characterization.

Artemia urumiana is bisexual population of the Lake Urmia of Iran. Its biomass was freeze dried and using its lyophilized powder, hydro-alcoholic extract was prepared and utilized in gold nanoparticles (Au NPs) synthesis. Six different Au NPs fabrication methods namely: microwave heating, hydrothermal, ultraviolet (UV) irradiation, ultrasonication, common heating using conventional heating, and self-assembling were utilized for Au NPs synthesis using A.urumiana extract. Gas chromatography analysis indicated that the prepared extract were contained numerous fatty acid methyl esters such as Hexadecanoic acid methyl ester. Results indicated that the formed NPs using heater and stirrer, and UV irradiation had minimum particle size of 25 and 94nm, respectively. However, as compared to the formed Au NPs using heater and stirrer technique, UV irradiation fabricated Au NPs with high zeta potential value of-32.5mV and small polydispersity value of 0.310. Results also demonstrated that the synthesized Au NPs using heater and stirrers, and UV irradiation had highest antioxidant activities of 13.7 and 11.9%, and bactericidal effects against Escherichia coli and Staphylococcus aurous bacteria strains, as compared to other fabricated Au NPs using other methods. There were insignificant (p>0.05) differences between these two attributes of the formed Au NPs.

COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity - United States, August 29-October 30, 2021.

Lesbian, gay, bisexual, and transgender (LGBT) populations have higher prevalences of health conditions associated with severe COVID-19 illness compared with non-LGBT populations (1). The potential for low vaccine confidence and coverage among LGBT populations is of concern because these persons historically experience challenges accessing, trusting, and receiving health care services (2). Data on COVID-19 vaccination among LGBT persons are limited, in part because of the lack of routine data collection on sexual orientation and gender identity at the national and state levels. During August 29-October 30, 2021, data from the National Immunization Survey Adult COVID Module (NIS-ACM) were analyzed to assess COVID-19 vaccination coverage and confidence in COVID-19 vaccines among LGBT adults aged ≥18 years. By sexual orientation, gay or lesbian adults reported higher vaccination coverage overall (85.4%) than did heterosexual adults (76.3%). By race/ethnicity, adult gay or lesbian non-Hispanic White men (94.1%) and women (88.5%), and Hispanic men (82.5%) reported higher vaccination coverage than that reported by non-Hispanic White heterosexual men (74.2%) and women (78. 6%). Among non-Hispanic Black adults, vaccination coverage was lower among gay or lesbian women (57.9%) and bisexual women (62.1%) than among heterosexual women (75.6%). Vaccination coverage was lowest among non-Hispanic Black LGBT persons across all categories of sexual orientation and gender identity. Among gay or lesbian adults and bisexual adults, vaccination coverage was lower among women (80.5% and 74.2%, respectively) than among men (88.9% and 81.7%, respectively). By gender identity, similar percentages of adults who identified as transgender or nonbinary and those who did not identify as transgender or nonbinary were vaccinated. Gay or lesbian adults and bisexual adults were more confident than were heterosexual adults in COVID-19 vaccine safety and protection; transgender or nonbinary adults were more confident in COVID-19 vaccine protection, but not safety, than were adults who did not identify as transgender or nonbinary. To prevent serious illness and death, it is important that all persons in the United States, including those in the LGBT community, stay up to date with recommended COVID-19 vaccinations.

Rapid Spread of Severe Fever with Thrombocytopenia Syndrome Virus by Parthenogenetic Asian Longhorned Ticks.

Severe fever with thrombocytopenia syndrome virus (SFTSV) is spreading rapidly in Asia. This virus is transmitted by the Asian longhorned tick (Haemaphysalis longicornis), which has parthenogenetically and sexually reproducing populations. Parthenogenetic populations were found in ≥15 provinces in China and strongly correlated with the distribution of severe fever with thrombocytopenia syndrome cases. However, distribution of these cases was poorly correlated with the distribution of populations of bisexual ticks. Phylogeographic analysis suggested that the parthenogenetic population spread much faster than bisexual population because colonization is independent of sexual reproduction. A higher proportion of parthenogenetic ticks was collected from migratory birds captured at an SFTSV-endemic area, implicating the contribution to the long-range movement of these ticks in China. The SFTSV susceptibility of parthenogenetic females was similar to that of bisexual females under laboratory conditions. These results suggest that parthenogenetic Asian longhorned ticks, probably transported by migratory birds, play a major role in the rapid spread of SFTSV.

Structural Heteropatriarchy and Birth Outcomes in the United States.

Emerging evidence links structural sexism and structural discrimination against lesbian, gay, and bisexual (LGB) populations to poor health outcomes, but studies have yet to examine the combined effects of these mutually reinforcing systems of inequality. Therefore, we developed a composite measure of structural heteropatriarchy-which includes state-level LGB policies, family planning policies, and indicators of structural sexism (e.g., women's political and economic position relative to men)-and examined its relationship to birth outcomes using data from Waves I to V of the National Longitudinal Study of Adolescent to Adult Health. Multivariate regression analyses demonstrated that higher levels of heteropatriarchy were associated with an increased risk of preterm birth and decreased birth weight, net of important covariates. There was no association between clinical low birth weight and heteropatriarchy, or interactions between heteropatriarchy and individuals' race, ethnicity or sexual identity, suggesting a negative effect of heteropatriarchy on birth outcomes for all pregnant people. This study demonstrates the importance of considering gender and sexuality as mutually reinforcing systems of oppression that impact population health. Future research should examine the impact of heteropatriarchy on additional health outcomes and in conjunction with other structural inequalities such as racism and transgender oppression.

Minority Stress and Mental Health: A Review of the Literature

ABSTRACT Lesbian, gay, bisexual, and transgender (LGBT) populations experience significant health disparities, theorized to result from LGBT specific minority stressors. The fully conceptualized Minority Stress Model was published more than 15 years ago. Minority stressors include external conditions and events, such as discrimination and victimization. Internal minority stressors include expectations of rejection and discrimination, concealment of minority identity, and internalizations of negative dominant cultural attitudes, beliefs, stereotypes, and values. Connection to sexual and gender minority communities is theorized to moderate the effects of minority stressors. In this integrative review, I examine two decades of research on minority stress. Based on this review, I highlight strengths and limitations of the model, and suggest next steps for moving minority stress research forward.

Current use of testosterone therapy in LGBTQ populations.

Testosterone therapy (TT) is a type of gender-affirming hormone therapy (GAHT) in lesbian, gay, bisexual, transgender, and genderqueer (LGBTQ) populations for gender dysphoria (GD), body uneasiness, and sexual dysfunction. The physical and physiological effects of TT vary widely depending on the dosing regimen and duration of treatment. An individualized approach prioritizing patient-specific desired effects in the context of pre-existing characteristics and health history is strongly recommended. Although TT is an effective treatment for many patients, there has been an increase in the illegitimate acquisition of TT in recent years. Non-judicious prescribing and lack of physician surveillance increases the risk of unintended side effects and potential serious health consequences.

Psychometric properties of the Thai version of the Internalized sexual stigma scale for research on lesbian, gay, bisexual, and transgender (LGBT) populations

ABSTRACT Internalized sexual stigma is an important contributor to LGBT mental health disparities. In Thailand, the absence of validated instruments represents a research barrier. The study’s purpose was to translate and evaluate the psychometric properties of the Revised Internalized Homophobia (IHP-R) scale. Based on the cross-cultural principle, team translation was applied. The IHP-R was translated by the principal author and reviewed by bilingual Thai nurses, and clarifications were made. Multidisciplinary experts provided back translation and reconciled the finalized Thai version. The psychometric properties were established in 412 Thai LGBT individuals. Data was collected via online and paper-pencil surveys and analyzed using SPSS. Most participants were male, age ranged 18–53, with moderate levels of internalized homophobia (M = 2.3, SD = 1.04). The inter-item and item-total correlations were .38-.63 and .55-.68. The content validity index was high (I-CVI, S-CVI/UA/Ave = 1). The exploratory factor analysis confirmed one construct of internalized sexual self-stigma (factor loading = .702–.816). Scores on IHP-R were correlated with stress and experiences of discrimination (r = .14 and .12). Internal consistency reliability was also high (Cronbach’s alpha coefficient = .83). The IHP-R Thai version has high psychometric properties and is appropriate for LGBT research in Thailand.

Suicide reporting of LGBTQI+ population in India: An analysis of online media reports of the past decade.

Imbalanced portrayal of suicide by the media can have adverse public health consequences. We aimed to evaluate the psychosocial context, as well as the quality of media reporting, of suicide among lesbian, gay, bisexual, transgender people, queer and intersex (LGBTQI+) population. A cross-sectional study was conducted to evaluate online news reports discussing the suicide of LGBTQI+ persons published between January 2011 and January 2021. Psychosocial factors associated with suicide were extracted from the reports. Quality of suicide reporting was checked against international as well as locally relevant reporting guidelines. A total of 135 suicide reports from five newspapers were analyzed. Multiple psychosocial stressors were reported in 54.5% of the suicides. Social stigma was the most common factor associated with LGBTQI+ suicide. Several breaches of reporting were noted in relation to mentioning the identity (55.6%) and method of suicide (54.3%) in the title of report and inclusion of the deceased's photograph (20.4%). Potentially helpful reporting characteristics, such as including educational information (2.2%), mentioning warning signs (12.6%) and suicide support service details (3.7%), were rarely practiced. Local language news articles displayed more frequent and serious violations compared to English news reports. Indian media reporting of suicide among LGBTQI+ persons is poorly adherent to reporting guidelines.

The (minority) stress of hiding: the effects of LGBT identities and social support on aging adults’ concern about housing

The lesbian, gay, bisexual, and/or transgender (LGBT) aging adult population is increasing rapidly in the United States. The literature reveals three shortcomings regarding research into the experiences of LGBT aging adults: (1) their needs have been largely overlooked, (2) there are few large-scale quantitative studies of this population, and (3) LGBT older adults are often treated as a monolith despite the potential for significant variations between subgroups under the umbrella. The current study addresses these issues by utilizing data from a nationwide AARP 2018 survey to study a central concern of LGBT aging adults: housing. Specifically, drawing upon the conceptual framework of minority stress, we examine how the LGBT identity of older people affects how concerned they are about having to hide their identity in order to find suitable housing as they age. Findings reveal (1) significant variations in the degree of worry among segments of the aging LGBT population, and (2) ameliorating factors such as social support may decrease the degree to which they worry about hiding their identity to access housing. These results may have implications for policies and practices aimed at increasing the community resilience available to support LGBT adults as they age.

Health and Access to Gender-Affirming Care During COVID-19: Experiences of transmasculine individuals and men assigned female sex at birth.

Since the onset of the COVID-19 pandemic, global research has suggested that the pandemic has negatively affected lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) populations, including by limiting health care access. There is little research on the impact of COVID-19 among transmasculine persons and men assigned female sex at birth (AFAB) in the United States, who face unique health care challenges outside of the pandemic context. Between May and June of 2020, 20 transmasculine individuals and AFAB men who have sex with men participated in semi-structured interviews about their experiences during the early months of the COVID-19 pandemic. Participants were asked how the pandemic affected their access to health care, overall health, and well-being. Interviews were analyzed using an inductive, thematic approach. Participants reported reduced access to in-person health care, which in some cases meant overdue hormone-related bloodwork and unmet health care needs. Most participants reported that they were able to maintain their testosterone regimen, although some were concerned about future access, citing anxiety about potential shortages. Three participants reported canceled or deferred gender-affirming procedures, which they were uncertain would be rescheduled soon. Participants generally reported that the expansion of telehealth improved access to care, particularly for gender-affirming psychotherapy that was otherwise inaccessible or inconvenient prior to the pandemic. Other salient themes include the pandemic’s impact on health behaviors and daily routines. Although the COVID-19 pandemic created new challenges for maintaining health, it also expanded access to gender-affirming health care, largely through the expansion of telehealth. Our findings provide new insights for supporting the health of transmasculine individuals and AFAB men.

Systematic review of the characteristics of LGBT homicides.

The lesbian, gay, bisexual and transgender (LGBT) population has long been excluded, a reality produced by social marginalization, which is still present in today's society. This article aims to present a quantitative profile of LGBT homicides, focusing on the crimes, victims, and perpetrators. We conducted a systematic review of quantitative studies on LGBT homicide using the following databases: PubMed Central (Medline), Latin American and Caribbean Center for Health Sciences Information (LILACS), Embase (Elsevier), Scopus (Elsevier), the Virtual Health Library (BVS), and APA PsycNet. The searches were run using terms taken from the Medical Subject Headings (MESHs) and Health Sciences Descriptors (DeCS - BVS). Sixteen studies were included. Homicides tended to involve a single victim and single perpetrator and occur at the victim's residence or in public locations. Victims were more likely to be older than the perpetrator and offenders were usually unknown to the victim. Transgender people were the most affected group and most of the victims in this group were aged under 30 years. The findings of this review confirm that LGBT homicides may be considered "hate crimes" and that victims are generally killed with firearms or non-firearms, beaten to death or suffocated.