Self-reported Sexual Identity Research Articles

Risk Behaviors and Perceptions Among Self-identified Men Who Have Sex with Men (MSM), Bisexuals, Transvestites, and Transgender Women in Western Guatemala

Guatemala has a concentrated HIV epidemic disproportionately affecting men who have sex with men (MSM) and transgender women. We recruited 205 self-identified MSM, bisexuals, transvestites, and transgender women in western Guatemala using long-chain peer referral, wherein "seed" participants were asked to invite as many as three acquaintances to participate in the study. Self-reported sexual or gender identity was MSM, 46%; bisexual, 28%; transvestite, 21%, and transgender woman, 5%. Median age of the participants was 23years, and 36% self-identified as being indigenous. Indigenous persons were more likely to self-identity as transvestite (32.9% vs 13.8%, P = 0.04), strongly perceive themselves at risk for HIV (87.7% vs 51.5%, P = 0.001), have had an HIV test in the last 12months and know the result (97.3% vs 85.4%, P = 0.008), and experience barriers to testing and treatment (86.3% vs 67.7%, P = 0.004). HIV prevention services for indigenous MSM should especially target transvestites and how to overcome stigmatization and barriers to care.

Exploring the Sexual Development Experiences of Black Bisexual Male Adolescents Over Time.

Scant research has sought to explore the development of dimensions of sexual orientation among Black bisexual male adolescents (BBMA). Understanding how sexual attractions, behaviors, and identities evolve among BBMA over time is crucial to understanding the most appropriate support strategies to provide during this developmental period. We sought to understand and describe the sexual orientation development experiences in a sample of BBMA over the course of 1year. We further sought to understand the sociocontextual factors that may play a role during this development process. Fifteen BBMA, aged 15-19years, were interviewed about sexual debut experiences (baseline) and were re-interviewed three times over a 1-year period about sexual attractions, behaviors, and identity at each follow-up point. A three-person team used inductive open coding to analyze each participant's data set. The mean Kinsey scale score for the sample was 2.93 (SD=1.2) most closely translating to "heterosexual/gay-equally." A case study analysis was used to identify themes related to sexual attractions, behavior, and identity over time, within and across participants. Among the sample of young men, two unique groups were identified based on self-reported sexual identity and experiences of same- and other-sex sexual attractions and behaviors over time. The first group consisted of seven young men who consistently described their sexual identity as bisexual from baseline to the final follow-up. These young men also described similar experiences related to same- and other-sex sexual and romantic attractions and more consistently described same- and other-sex sexual behaviors. The second group consisted of eight young men that described changing sexual identity and same- and other-sex sexual romantic attractions over time. Participants described sociocontextual factors such as religion, masculinity, and homophobia played during their development. Findings from this study underscore the complexity of sexual orientation development and sociocultural factors and expectations that may influence sexual identity and behavior among BBMA.

Alcohol Outcomes by Sexual Orientation and Race/Ethnicity: Few Findings of Higher Risk.

This study sought to confirm a previously identified race by sexual orientation interaction and to clarify men's alcohol-related risk by using an expanded classification of sexual orientation. We collapsed three waves of National Alcohol Survey data, restricting the analytic sample to White (n = 5,689), Black (n = 1,237), and Latino (n = 1,549) men with complete information on sexual orientation and alcohol use. Using self-reported sexual identity and behavior, respondents were categorized as exclusively heterosexual (referent), behaviorally discordant heterosexuals (i.e., heterosexual identity and same-sex partners), or gay/bisexually identified men. We used multivariable logistic regression to model lifetime alcohol dependence symptoms, lifetime drinking-related consequences, and past-year hazardous drinking, controlling for age, education, employment, and relationship status and accounting for the complex survey design. There was no difference in risk of past-year hazardous drinking and lifetime drinking-related consequences between heterosexual, behaviorally discordant heterosexual, and gay/bisexual men, independent of race/ ethnicity. Among Black men, behaviorally discordant heterosexuals had three-fold higher odds of lifetime alcohol dependence symptoms than exclusively heterosexual peers (aOR = 3.30, 95% CI [1.19, 9.18], p = .02). Gay/bisexual Latino men had marginally significantly lower odds of lifetime alcohol dependence symptoms (aOR = 0.36, 95% CI [0.12, 1.03], p = .06). There is little support for broad statements of greater alcohol risk among gay/bisexual men; however, for some subgroups and outcomes the direction and degree of risk depend on race/ ethnicity. Thus, this study underscores the importance of considering the potential interaction of sexual orientation and race/ethnicity, which may exacerbate or attenuate.

Assessing the Relationship Between Sexual Concordance, Sexual Attractions, and Sexual Identity in Women.

On average, there is a gender difference in sexual concordance, with men exhibiting greater agreement between genital and self-reported sexual arousal, relative to women. Much less is known about the substantial variation in women's sexual concordance; women's genital and self-reported sexual responses may correlate strongly and positively, not at all, or even strongly negatively. The within-gender variation in sexual concordance suggests that individual differences may be related to sexual concordance. We examined whether sexual concordance varies as a function of sexual orientation (based on self-reported sexual attractions and sexual identity labels) in a sample (N=76) that included exclusively androphilic, predominantly androphilic, ambiphilic, and predominantly/exclusively gynephilic women. Participants viewed sexual and nonsexual stimuli that varied by actor gender while their vaginal vasocongestion and subjective sexual responses were measured. Women's sexual concordance varied as a function of their sexual attractions; women with any degree of gynephilia exhibited higher sexual concordance than exclusively androphilic women across a variety of sexual concordance measures, and these effects were demonstrated using correlation and multi-level modeling analyses. Only sexual concordance based on overall feelings of arousal varied by sexual identity, with heterosexual women exhibiting the lowest sexual concordance. Stimulus gender significantly influenced sexual concordance for most groups of women: Ambiphilic and predominantly/exclusively gynephilic women exhibited greater sexual concordance to female stimuli and exclusively androphilic women exhibited greater sexual concordance to male stimuli. These findings suggest that sexual orientation (particularly one's degree of gynephilia) may explain some of the within-gender variation seen in women's sexual concordance.

What's In an Identity Label? Correlates of Sociodemographics, Psychosocial Characteristics, and Sexual Behavior Among African American Men Who Have Sex With Men.

African American men who have sex with men (AAMSM) are vastly overrepresented among people with HIV/AIDS. Using data from 595 AAMSM in Philadelphia, we explored differences in sociodemographics, psychosocial characteristics related to beliefs about ethnicity, sexuality and masculinity, and sexual behavior with men and women by self-reported sexual identity (gay, bisexual, down low, straight). Roughly equivalent numbers identified as gay (40.6%) and bisexual (41.3%), while fewer identified as straight (7.6%) or down low (10.5%), with significant differences in age, income, history of incarceration, HIV status, alcohol and drug problems, childhood sexual abuse, and connection to the gay community evident among these groups. Analysis of psychosocial characteristics theorized to be related to identity and sexual behavior indicated significant differences in masculinity, homophobia, and outness as MSM. Gay and straight men appeared to be poles on a continuum of frequency of sexual behavior, with bisexual and down low men being sometimes more similar to gay men and sometimes more similar to straight men. The percentage of men having total intercourse of any kind was highest among down low and lowest among gay men. Gay men had less intercourse with women, but more receptive anal intercourse with men than the other identities. There were no significant differences by identity in frequency of condomless insertive anal intercourse with men, but gay men had significantly more condomless receptive anal intercourse. There were significant differences by identity for condomless vaginal and anal intercourse with women. This study demonstrates the importance of exploring differences in types of sex behavior for AAMSM by considering sexual identity.

Teen Pregnancy Among Sexual Minority Women: Results From the National Longitudinal Study of Adolescent to Adult Health

PurposeThe purpose of this study was to explore the association between sexual orientation and teen pregnancy (before age 20 years) in a U.S. nationally representative cohort of young adult females aged 24–32 years. MethodsA total of 5,972 participants in Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health were included. Self-reported sexual orientation identity was categorized as heterosexual, and three sexual minority (SM) groups: mostly heterosexual, bisexual, and lesbian (combining “mostly homosexual” and “100% homosexual”). Stepwise multivariate regression models were fit to compare odds of teen pregnancy and relative risk ratios of timing of teen pregnancy, between heterosexual and SM groups, adjusting for sociodemographic characteristics, sexual victimization history, and sexual risk behaviors. ResultsAfter adjusting for sociodemographics and sexual victimization, bisexual women had significantly higher odds than heterosexual peers of teen pregnancy (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.05–2.75); this association was marginally significant after adjusting for sexual risk behaviors. Bisexuals were also more likely to have an early (before age 18 years) teen pregnancy (OR = 2.04; 95% CI = 1.17–3.56). In contrast, lesbian women were significantly less likely to have a teen pregnancy than heterosexual (OR = .47; 95% CI = .23–.97), mostly heterosexual (OR = .46; 95% CI = .21–.99), and bisexual (OR = .29; 95% CI = .12–.71) women in final models. ConclusionsExpanding on extant literature, we found opposing risk patterns for teen pregnancy between bisexual and lesbian women, likely due to distinct patterns of sexual risk taking. Findings suggest that SM-inclusive teen pregnancy prevention efforts tailored to meet the unique needs of SM young women, particularly bisexuals, are needed.

Association of Alcohol Misuse With Sexual Identity and Sexual Behavior in Women Veterans

ABSTRACTBackground: Sexual minority women report greater alcohol misuse than heterosexual women in the general population, with more pronounced differences found among younger age groups. It is unknown whether these differences exist among women veterans. Objective: We evaluated differences in alcohol misuse across two dimensions of sexual orientation (identity and behavior) among women veterans, and examined whether these differences were modified by age. Methods: Women veterans were recruited via the internet to participate in an online survey. Participants provided information on their self-reported sexual identity and behavior and responded to the validated 3-item Alcohol Use Disorders Identification Test-Consumption questionnaire (AUDIT-C). Regression models were used to compare the prevalence of alcohol misuse (AUDIT-C ≥ 3) and severity (AUDIT-C scores) across sexual identity and behavior and to test effect modification by age. Results: Among the 702 participants (36% lesbian/bisexual), prevalence and severity of alcohol misuse varied by both sexual identity and behavior, but there were significant interactions with age. Prevalence and severity of alcohol misuse were higher among relatively younger self-identified lesbians compared to heterosexual women. Similarly, both prevalence and severity of alcohol misuse were generally higher among younger women who had any sex with women compared to those who had sex only with men. Conclusions/Importance: In this online study of women veterans, younger sexual minority women were more likely to screen positive for alcohol misuse, and they had more severe alcohol misuse, than their heterosexual counterparts. Prevention and treatment efforts focused specifically on sexual minority women veterans may be needed.

To Be or Not to Be

Inferring sexual behavior of a stigmatized minority through self-reported sexual identity is subject to misclassification and can lead to biased results. We quantify the degree of this misclassification and perform a Bayesian correction of the risk of HIV infection in relation to self-reported sexual behavior. Sensitivity and specificity of self-reported men who have sex with men in ascertaining sexual behavior was derived from validation data, as was the informative prior on the association of same-sex behavior with self-reported HIV infection. Using these priors, we performed two separate Bayesian analyses of National Epidemiologic Survey on Alcohol and Related Conditions data for the odds of self-reported HIV positivity, adjusting for differential misclassification of self-reported same-sex behavior indicated by either partner gender or sexual identity. We found differential exposure misclassification with specificity exceeding sensitivity, and higher misclassification rates based on sexual identity compared with partner gender. Sexual identity and partner gender displayed different associations with HIV infection in the raw data but these became virtually identical when adjusted for estimates of misclassification of sexual behavior by these two indicators. The estimate of prevalence of same-sex behavior associated with an elevated risk of HIV infection decreased after adjustment for misclassification. Studies of risk due to same-sex behavior are likely biased when they rely on self-identification for ascertainment of risk factors, especially when self-reported identity is used. The implications of our findings on risk modeling cannot be assumed to be trivial due to substantial shifts in distributions of risk and prevalence of exposure.

Differences in Weight-Related Behavioral Profiles by Sexual Orientation Among College Men: A Latent Class Analysis.

To identify and describe homogenous classes of male college students based on their weight-related behaviors (e.g., eating habits, physical activity, and unhealthy weight control) and to examine differences by sexual orientation. Study design was a cross-sectional sample of 2- and 4-year college students. Study setting was forty-six 2- and 4-year colleges in Minnesota. Study subjects comprised 10,406 college males. Measures were five categories of sexual orientation derived from self-reported sexual identity and behavior (heterosexual, discordant heterosexual [identifies as heterosexual and engages in same-sex sexual behavior], gay, bisexual, and unsure) and nine weight-related behaviors (including measures for eating habits, physical activity, and unhealthy weight control). Latent class models were fit for each of the five sexual orientation groups, using the nine weight-related behaviors. Overall, four classes were identified: "healthier eating habits" (prevalence range, 39.4%-77.3%), "moderate eating habits" (12.0%-30.2%), "unhealthy weight control" (2.6%-30.4%), and "healthier eating habits, more physically active" (35.8%). Heterosexual males exhibited all four patterns, gay and unsure males exhibited four patterns that included variations on the overall classes identified, discordant heterosexual males exhibited two patterns ("healthier eating habits" and "unhealthy weight control"), and bisexual males exhibited three patterns ("healthier eating habits," "moderate eating habits," and "unhealthy weight control"). Findings highlight the need for multibehavioral interventions for discordant heterosexual, gay, bisexual, and unsure college males, particularly around encouraging physical activity and reducing unhealthy weight control behaviors.

Sexual Orientation and Risk of Pregnancy Among New York City High-School Students.

We examined associations between sexual orientation and pregnancy risk among sexually experienced New York City high-school students. We analyzed data from 2005, 2007, and 2009 New York City Youth Risk Behavior Surveys. We excluded students who had never engaged in sexual intercourse, only had same-gender sexual partners, or had missing data on variables of interest, resulting in a final sample of 4892 female and 4811 male students. We employed multivariable logistic regression to examine pregnancy risk by sexual orientation, measured as self-reported sexual identity and gender of sexual partners, with adjustment for demographics and sexual behaviors. We stratified analyses by gender. Overall, 14.3% of female and 10.8% of male students had experienced a pregnancy. Students who identified as gay, lesbian, or bisexual or reported both male and female sexual partners had higher odds of pregnancy than heterosexual students or students who only had opposite-gender sexual partners. Sexual behaviors accounted for higher odds of pregnancy among female, but only partially accounted for higher odds of pregnancy involvement among male, sexual-minority students. Sexual orientation should be considered in future adolescent pregnancy-prevention efforts, including the design of pregnancy-prevention interventions.

Life satisfaction and sexual minorities: Evidence from Australia and the United Kingdom

Very little is known about how the differential treatment of sexual minorities could influence subjective reports of overall well-being. This paper seeks to fill this gap. Data from two large surveys that provide nationally representative samples for two different countries – Australia and the UK – are used to estimate a simultaneous equations model of life satisfaction. The model allows for self-reported sexual identity to influence a measure of life satisfaction both directly and indirectly through seven different channels: (i) income; (ii) employment; (iii) health (iv) marriage and de facto relationships; (v) children; (vi) friendship networks; and (vii) education. Lesbian, gay and bisexual persons are found to be significantly less satisfied with their lives than otherwise comparable heterosexual persons. In both countries this is the result of a combination of direct and indirect effects.

Determinants of Homosexuality-Related Stigma Among Men Who Have Sex with Men in Hanoi, Vietnam

ABSTRACTObjectives: The objective of this study was to examine the levels and correlates of homosexual stigma among men who have sex with men (MSM) in Hanoi, Vietnam. Methods: A cross-sectional study design using a respondent-driven sampling (RDS) method was conducted in 2011 to collect data from 451 MSM in Hanoi, Vietnam. A cross-validation technique and factor analysis were used to refine the constructs of a homosexual stigma scale. Data weighted to adjust for the RDS design were evaluated to estimate the population-based prevalence of homosexual stigma, depression, drug and alcohol use, multiple sexual partners, and unprotected sex. Weighted logistic regression was used to determine demographic, psychosocial, and behavioral predictors of three forms of homosexuality-related stigma. Results: Enacted homosexual stigma was significantly linked to place of birth (adjusted odds ratio [AOR] = 0.58; 95% confidence interval [CI] [0.36, 0.95]), self-reported sexual identity (AOR = 0.63; 95% CI [0.41, 0.98]), multiple sexual partners (AOR = 2.24; 95% CI [1.21, 4.14]), and unprotected sex (AOR = 2.83; 95% CI [1.64, 4.87]). High levels of self-homosexual stigma were reported and were significantly associated with being married/divorced/separated (AOR = 2.49; 95% CI [1.02, 6.09]), being in a monogamous sexual relationship (AOR = 0.59; 95% CI [0.36, 0.98]), depression (AOR = 2.21; 95% CI [1.21, 4.06], and AOR = 3.13; 95% CI [1.76, 5.27]). Conclusions: The study presents the evidence for understanding the factors contributing to different forms of homosexual stigma and provides important evidence for evidence-based intervention development for stigma reduction targeting MSM in Vietnam.

What Can Life Satisfaction Data Tell Us About Discrimination Against Sexual Minorities? A Structural Equation Model for Australia and the United Kingdom

Very little is known about how the differential treatment of sexual minorities could influence subjective reports of overall well-being. This paper seeks to fill this gap. Data from two large surveys that provide nationally representative samples for two different countries – Australia (the HILDA Survey) and the UK (the UK Household Longitudinal Study) – are used to estimate a simultaneous equations model of life satisfaction. The model allows for self-reported sexual identity to influence a measure of life satisfaction both directly and indirectly through seven different channels: (i) income; (ii) employment; (iii) health (iv) partner relationships; (v) children; (vi) friendship networks; and (vii) education. Lesbian, gay and bisexual persons are found to be significantly less satisfied with their lives than otherwise comparable heterosexual persons. In both countries this is the result of a combination of direct and indirect effects.

Socialization patterns and their associations with unprotected anal intercourse, HIV, and syphilis among high-risk men who have sex with men and transgender women in Peru.

The association of socialization patterns with unprotected anal intercourse (UAI) and HIV/STI prevalence remains underexplored in men who have sex with men (MSM) and transgender women (TW) in developing country settings. We evaluated the correlation of UAI, HIV, and syphilis with MSM/TW venue attendance and social network size among high-risk MSM and TW in Peru according to self-reported sexual identity. Frequency of venue attendance and MSM/TW social network size were lowest among heterosexual MSM and highest among TW respondents. Attendance (frequent or occasional) at MSM/TW venues was associated with increased odds of insertive UAI among heterosexual participants. Frequent venue attendance was associated with increased odds of receptive UAI among gay/homosexual, bisexual, and TW participants. Further investigation of the differing socialization patterns and associations with HIV/STI transmission within subgroups of Peruvian MSM and TW will enable more effective prevention interventions for these populations.

What Can Life Satisfaction Data Tell Us About Discrimination Against Sexual Minorities? A Structural Equation Model for Australia and the United Kingdom

Very little is known about how the differential treatment of sexual minorities could influence subjective reports of overall well-being. This paper seeks to fill this gap. Data from two large surveys that provide nationally representative samples for two different countries – Australia (the HILDA Survey) and the UK (the UK Household Longitudinal Study) – are used to estimate a simultaneous equations model of life satisfaction. The model allows for self-reported sexual identity to influence a measure of life satisfaction both directly and indirectly through seven different channels: (i) income; (ii) employment; (iii) health (iv) partner relationships; (v) children; (vi) friendship networks; and (vii) education. Lesbian, gay and bisexual persons are found to be significantly less satisfied with their lives than otherwise comparable heterosexual persons. In both countries this is the result of a combination of direct and indirect effects.

Substance Use and Mental Health Disorders Among Heterosexual Identified Men and Women Who Have Same-Sex Partners or Same-Sex Attraction: Results from the National Epidemiological Survey on Alcohol and Related Conditions

This study examined sexual orientation discordance, a mismatch between self-reported sexual identity and sexual behavior or sexual attraction, by describing the characteristics, substance use disorders, and mental health risks of heterosexual identified individuals who endorsed this pattern of sexual identification, behavior, and attraction. Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we created three groups based on participants' reported sexual identity and either their sexual behavior or sexual attraction: heterosexual concordant, homosexual concordant, and heterosexual discordant. Bivariate models assessed the relationship of discordant status and demographic correlates, lifetime substance use disorders, and mental health diagnoses. Logistic regression models tested associations between both behavior discordance and attraction discordance and the likelihood of having lifetime disorders of substance use, major depression, and generalized anxiety. Results of this study provided evidence of varying levels of substance use and mental health disorder risk by gender, discordance status, and discordance type. Behavioral discordance was associated with increased risk of mental health and substance use disorder among women (compared to heterosexual concordance). Findings among men were less consistent with heightened risk of alcohol and inhalant use only. Attraction discordance was notably different from behavioral discordance. The odds of substance use and mental health disorders were the same or lower compared with both the heterosexual and homosexual concordance groups. Future research should begin to test theoretical explanations for these differences.

Sexual Orientation Disparities in Sexually Transmitted Infections: Examining the Intersection Between Sexual Identity and Sexual Behavior

The terms MSM (men who have sex with men) and WSW (women who have sex with women) have been used with increasing frequency in the public health literature to examine sexual orientation disparities in sexual health. These categories, however, do not allow researchers to examine potential differences in sexually transmitted infection (STI) risk by sexual orientation identity. Using data from the National Longitudinal Survey of Adolescent Health, this study investigated the relationship between self-reported STIs and both sexual orientation identity and sexual behaviors. Additionally, this study examined the mediating role of victimization and STI risk behaviors on the relationship between sexual orientation and self-reported STIs. STI risk was found to be elevated among heterosexual-WSW and bisexual women, whether they reported same-sex partners or not, whereas gay-identified WSW were less likely to report an STI compared to heterosexual women with opposite sex relationships only. Among males, heterosexual-identified MSM did not have a greater likelihood of reporting an STI diagnosis; rather, STI risk was concentrated among gay and bisexual identified men who reported both male and female sexual partners. STI risk behaviors mediated the STI disparities among both males and females, and victimization partially mediated STI disparities among female participants. These results suggest that relying solely on behavior-based categories, such as MSM and WSW, may mischaracterize STI disparities by sexual orientation.

Prevalence and Stability of Self-Reported Sexual Orientation Identity During Young Adulthood

Based on date from Wave 3 and Wave 4 from National Longitudinal Survey of Adolescent Health (N=12,287), known as Add Health, the majority of young adults identified their sexual orientation as 100% heterosexual. The second largest identity group,‘‘mostly heterosexual,’’was larger than all other nonheterosexual identities combined. Comparing distributions across waves, which were approximately 6 years apart, stability of sexual orientation identity wasmore common than change. Stability was greatest among men and those identifying as heterosexual. Individuals who identified as 100% homosexual reported nearly the same level of stability as 100% heterosexuals. The bisexual categorywas themost unstable, with one quarter maintaining that status at Wave 4. Bisexual men who changed their identity distributed themselves among all other categories; among bisexual women, themost common shiftwas toward mostly heterosexual. Reflecting changes in identity, the proportion of heterosexuals decreased between the two waves.

Mostly Heterosexual and Mostly Gay/Lesbian: Evidence for New Sexual Orientation Identities

A sample of 1,784 individuals responded to an online survey advertised on the Facebook social networking website. We explored the sexual orientation continuum by focusing on three components: self-reported sexual orientation identity, sexual attraction, and sexual partners. Results supported a 5-category classification of identity (heterosexual, mostly heterosexual, bisexual, mostly gay/lesbian, gay/lesbian) in that two added identity labels (mostly heterosexual and mostly gay/lesbian) were frequently chosen by participants and/or showed unique patterns of attraction and partners, distinct from their adjacent identities (heterosexual and bisexual, and bisexual and gay/lesbian, respectively). Those who reported an exclusive label (heterosexual, gay/lesbian) were not necessarily exclusive in other components; a significant minority of heterosexuals and the majority of gays/lesbians reported some attraction and/or partners toward their nonpreferred sex. The five identity groups differed in attraction and partners in a manner consistent with a continuous, rather than a categorical, distribution of sexual orientation. Findings also supported a sexual orientation continuum as consisting of two, rather than one, distinct dimensions (same- and other-sex sexuality). Having more same-sex sexuality did not necessarily imply having less other-sex sexuality, and vice versa. More men than women were at the exclusive ends of the continuum; however, men were not bimodally distributed in that a significant minority reported nonexclusivity in their sexuality.

P1-S2.37 Incidence of urethral discharge syndrome among men who have sex with men and associated risk factors in India; a cohort analysis of clinic attendees

BackgroundMonitoring data from a cohort of men who have sex with men (MSM) attending 421 clinics located in six states of India from January 2004 to December 2009 were studied....