Abstract
A diagnosis of gender dysphoria remains the primary requirement for transgender people to receive medical and legal gender affirmation services. Three focus groups conducted in 2018 with transgender and gender diverse (TGD) adolescents were assessed to understand how they define and use the term dysphoria and how the clinical discourse of gender dysphoria relates to their sense of self and overall wellness. The 21 participants (age 12–18) were primarily White (n = 19, 90%; Hispanic n = 2, 10%). Thirteen adolescents had a masculine identity, 2 feminine, and 6 genderqueer/nonbinary. TGD youth understood the clinical definition of gender dysphoria but expanded its use; reported stigma as the cause of some of their dysphoria; and used their conceptualization of dysphoria to find self-acceptance. This study highlights the perceived harm and potential limitations of using diagnostic language to define identity. However, through rescripting and self-definition, TGD youth exercise personal agency and reject stigma.
Introduction
To date, the experience of adolescent development and identity formation for transgender and gender diverse (TGD) youth has been under-described. Transgender refers to anyone whose gender identity does not align with their sex assigned at birth, while gender diverse refers to anyone whose gender expression or identity differs from societal expectations of men/boys or girls/women (i.e., gender nonconforming, gender expansive, gender fluid, etc.). Well-accounted for are the vulnerabilities of TGD adolescents: TGD youth experience more violent victimization and bullying, depression and suicidality, and substance use than their cisgender peers (James et al., 2016; Johns et al., 2019; Lefevor et al., 2019; Reisner, Greytak, et al., 2015; Reisner, Vetters, et al., 2015). These health disparities are largely attributed to minority stress, or the process by which social stigma against transgender identities is enacted through discrimination and harassment (Hendricks & Testa, 2012; Meyer, 1995). Further, lack of gender affirmation, including in health care settings, may contribute to delayed or forgone medical care (Goldenberg et al., 2019, 2021). This underscores the necessity of research to both understand and de-stigmatize TGD development from a gender affirming perspective.
The current Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) of the American Psychiatric Association (APA) defines dysphoria as a mental disorder in which A) there is a marked incongruence between one’s experienced and one’s assigned gender, and B) the incongruence is associated with clinically significant distress or impairment in areas of functioning (American Psychiatric Association, 2013). Yet, the understanding and classification of gender-related disorders continues to evolve (for review, Beek et al., 2016). Currently, APA makes a point to specify gender “dysphoria as the clinical problem, not identity per se” (American Psychiatric Association, 2013); indicating a move away from pathologizing identity. While gender identity is indeed not a disorder, some TGD people do require medical affirming treatment, keeping gender dysphoria and identity a matter of clinical concern. The World Professional Association for Transgender Health (WPATH) have established a global, professional consensus on evidence-based Standards of Care for gender affirming treatment that acknowledges and respects TGD identities (Coleman et al., 2022).
Despite these advances, being transgender is still considered by some, and still potentially implied by the DSM-5 (Davy & Toze, 2018), to be a psychiatric illness. Upholding these assumptions of disorder, a psychiatric diagnosis of gender dysphoria remains the primary requirement for transgender people to receive medical and legal gender affirmation services in the United States (Coleman et al., 2022; van Anders et al., 2014). Additionally, while the intention of clinical and research communities may be to shift away from pathologizing identity, the continued use of the diagnostic term gender dysphoria may undermine this shift (Davy & Toze, 2018). Imprecise use of diagnostic language may be causing or continuing unnecessary harm (Ashley, 2021).
Qualitative work on the phenomenology of gender dysphoria in teens highlights the role relational dynamics and social norms can play in TGD youth’s experience of gender dysphoria (Jessen, Haraldsen, et al., 2021; Jessen, Waehre, et al., 2021). Additionally, the impact of negative depictions of transgender individuals and issues in media, symbolism and messaging in the environment, and direct or indirect experiences of identity invalidation and non-affirmation have been shown to have cognitive and psychological consequences for TGD youth (Clary et al., 2023; Johnson et al., 2020; Pham et al., 2020; Testa et al., 2015). Thus, it is plausible that clinical terminology may act like negative messaging. The clinical association of a term commonly used by TGD youth may impact how they understand themselves and their environment, with social and emotional consequences.
The Minority Stress Model, proposed by Meyer (2003) and adapted for gender minorities by Hendricks and Testa (2012), describes how the impact of stressors uniquely experienced by people with minority identities lead to greater mental health and substance use problems which may be buffered by resilience. Reframed, the transgender stigma experienced at structural, interpersonal, and individual levels impacts health and well-being (White Hughto et al., 2015). For example, issues around bathroom use in schools or access to affirming medical care; family rejection or peer harassment; and internalized feelings of transphobia are stigmas regularly experienced by today’s TGD youth. Indeed, prior research asserts minority stress and stigma significantly contribute to adverse health outcomes including violence, depression, anxiety, shame and self-hatred, suicide risk, and limits socioeconomic opportunities (Askevis-Leherpeux et al., 2019; Chodzen et al., 2019; Cooper et al., 2020; Hendricks & Testa, 2012; White Hughto et al., 2015). Importantly, while stressors and stigma lead to negative health outcomes, identity pride, community connectedness, and other examples of resilience act to buffer the impacts of minority stress on mental health and substance use (Hendricks & Testa, 2012; Jones & Hillier, 2013; McLemore, 2018; Shelton et al., 2018; Singh et al., 2014; Testa et al., 2015).
In this study we analyzed transcripts of focus groups with TGD adolescents about how they think, feel, and experience gender. We were generally interested in how youth understand and use the term dysphoria; how this terminology is working for adolescents; and what effect it may be having on their lives (Table 1).
Research Questions.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Methods
We analyzed focus group data with TGD teens from a project to develop an inclusive, multi-dimensional measure of gender for adolescents. The protocol was approved by the Institutional Review Board at the University of Vermont. Prior to data collection, written permission was obtained from a parent/guardian and written informed assent (or consent if 18 years old) was obtained from youth.
Recruitment
Participants were recruited by distributing flyers in the Burlington, VT and Rochester, NY areas and by inviting community organizations serving LGBTQ youth to recruit. Recruitment materials invited adolescents who “identify as transgender or gender diverse. . .to participate in a 90 minute discussion. . .to help us in a research project about gender identity and expression.” No participants were excluded from participation.
Participants and Data Collection
Twenty-one adolescents (12–18 years; x̄=14.4 years, sd = 1.6) participated in 3 focus groups in 2018 (2 in VT) consisting of 4, 7, and 10 members. Participants were primarily White (n = 20) and assigned female at birth (n = 17) (Table 2). Each focus group began with a scripted, open-ended prompt to explore how youth think about their gender. Once underway, discussion was primarily participant-led; with scripted, follow-up prompts as needed to ensure that gender constructs including identity, expression, dysphoria, dynamics (stability and/or fluidity), expectations (gender roles), and positive attributes associated with their identity were discussed. Focus groups lasted no more than 90 minutes and were audio recorded. Participants were compensated for their time.
Participant Demographics (N = 21, ages 12–18 Years Old).
Gender identities were written-in by participants and then categorized by authors.
Core based statistical area is metro (>50 k population) or micro (10 k–50 k population) by zip code. Zip codes were not provided by all participants.
Data Analysis
Focus group recordings were transcribed verbatim. Data were analyzed using principles of thematic analysis (Braun & Clarke, 2006) using; (1) a deductive approach organized around the DSM-5 criteria of “gender dysphoria” and (2) an inductive approach to identify additional uses of the word “dysphoria.” Risk and protective factors were also coded and points of intersection were pursued. Three researchers (SLD, MMJ, and AEE) refined the codebook using a subjective assessment approach (Guest et al., 2012) and iteratively revised the codes until they agreed on all meanings and applications. Then, these three researchers read and coded each transcript, coming together to reconcile any coding disagreements. NVivo version 12.0.0 was used to organize and analyze coded transcripts.
Positionality Statement
Study design, data collection, analysis and writing were done in collaboration and consultation with clinicians and researchers with lived-experience as transgender and gender queer individuals. The primary author (SLD) is a White, cisgender female employed as a university research specialist.
Results
Theme 1: TGD Youth Engage Critically With the Clinical Definition of Gender Dysphoria
TGD youth in this sample demonstrated a deep familiarity with the clinical definitions of gender dysphoria, and frequently used this terminology to describe their experiences around identity and expression. Youth used dysphoria as shorthand to refer to reminders of incongruence between their gender identity/expression and their sex assigned at birth, as well as the extreme distress that sometimes accompanied that incongruence, consistent with DSM-5 criteria A and B, respectively (American Psychiatric Association, 2013).
I only had dysphoria when it came to my chest, you know that’s why I had surgery. And it was really debilitating. And when I like looked in the mirror in the mornings . . . when I saw my chest I didn’t think “oh that’s ugly.” Like it wasn’t a thing of like, “oh that’s- I wish I were fitter” or “I wish I weighed less”. . . It was like, “that doesn’t belong on my body.” Like, “this is alien to me.” Like, “this is something completely like wrong here.” Like someone cut and pasted like an image that didn’t belong to me.
Rigid, cis-normative (binary) definitions of dysphoria by medical professionals can exclude some TGD youth, particularly nonbinary youth, from medical care.
I was denied by a surgeon. When I explained to her my situation that—she’s like, “well my experience with trans men are, these uh, these men who uh grew up loving trucks and like you know like told their parents they wanted to be a boy or have like a penis. And you don’t fit that narrative and so I think you should come back when you’re less confused.”
However, even a TGD youth with a diagnosis may be denied gender affirming treatment based on physicians’ expectations.
I had to, as you said, want to be a cis man to get the surgery. And we had to do a lot of fighting to say like, “I’ve been diagnosed with dysphoria. Like, you know, medically like you gotta help me—whether or not I fit this cis-normative narrative.”
This youth understood dysphoria as a necessary diagnosis for accessing affirming care.
Despite recent efforts of the medical and research communities to distinguish dysphoria as the pathology rather than identity, TGD youth felt the two were still conflated. As one youth put it, “Because gender dysphoria, ‘medically’, and I hate saying this, is like what makes you trans.” Youth repeatedly referred to the medicalization of their identity and no youth seemed to be aware of recent efforts by the psychiatric community to disentangle the two—“People connect being transgender and being queer, and everything like that, to mental illnesses, which is way far from the truth.” Participants insisted that dysphoria is not a requirement for being TGD. As one youth simply stated, “I feel like you don’t need dysphoria to be trans.”
Youth feared that pathologization of TGD identity can be used as evidence to justify transphobia and lend credibility to trans-specific discrimination.
It’s like what TERF [Trans Exclusionary Radical Feminist] ideology is. . . .They like are asking, “are you sure about this” and “is this is just like the result of like a mental illness?”
Subverting any understanding of TGD identities as part of natural variation in human gender encourages dysfunction narratives.
Theme 2: TGD Youth Have an Expansive Understanding of Gender Dysphoria That Contrasts With a Pathologized Identity
Youth criticized the idea that their identity necessitated a diagnosis, by pushing back on the pathology narrative.
Yeah, like why are cis people so obsessed with the fact that it’s a, it’s an illness, it’s a mental illness and that they’re labeling it as “gender dysphoria” and they use all these ugly terms like “medical condition,” “diagnosis”? And those aren’t inherently ugly words but to be, to have your identity and sense of self be called like a diagnosis, it’s hurtful in a lot of ways. It’s hurtful. And it’s—Stop doing that. Please.
In fact, though most participants experienced significant psychological distress that they themselves labeled as dysphoria, many also challenged the idea of gender dysphoria as a legitimate diagnosis. “Stop calling it ‘you’re being diagnosed with gender dysphoria’ because it’s not an illness that needs to be diagnosed. Just believe us.”
Conversely, some TGD teens described a lack of psychological distress and dysphoria as instances of incongruence with minor discomfort or no accompanying distress. For example, “It’s like trying to get into a sweater that doesn’t fit and it’s itchy and stuff.” Another youth used similar language, “For me dysphoria is just a sense of like this isn’t right, like this doesn’t fit me.” These experiences do not meet diagnostic criteria and were consistent with a rejection of pathology.
Medicalization was especially challenged by youth who did not desire or require medical gender-affirmation services. They felt they had no condition requiring treatment, despite experiencing gender-related distress.
Yeah. I don’t have like a very, I don’t know what you’d call it, “traditional trans dysphoria.” I definitely don’t have it because I don’t, I don’t feel the need to transition as much. I feel, like I feel trans. I feel definitely out of the binary as far as that goes, which would identify me as trans, but like I don’t feel as like, like I don’t feel like I need to transition as much.
Understanding dysphoria as only a condition to be treated with medical transition to achieve cis-normative binary presentation, limits whose experiences count. Thus, some nonbinary participants seemed uniquely uncomfortable using the term dysphoria to describe their distress. “I also experience dysphoria which is completely weird for someone that’s nonbinary. Um. Because like how does that work exactly? But really it’s like, I know who I’m not.”
Alternatively, the medicalization of TGD experiences through gender dysphoria kept some youth who don’t suffer from significant distress from affirming their TGD identity.
I know for a lot of people it’s a lot worse for them. Like they feel everything is dysphoria. But for me that’s not the case. And then again, it’s like the same thing. But am I really even trans because I don’t feel this? But this person, who is trans feels this, so what’s wrong with me or whatever?
Despite the ambivalence some participants expressed about their own dysphoria, all three focus groups recognized it as a reality for many. They expressed a desire for an understanding of gender dysphoria to be more inclusive of nonbinary and gender-fluid individuals.
Theme 3: TGD Youth Recognize Dysphoria as the Result of Interpersonal Experiences and Transgender Stigma, Rather Than Solely an Internalized Sense of Bodily Dissatisfaction
Participants described external stressors as causing some, or all their dysphoria. At times youth described dysphoria in relation to social interactions, rather than an internal experience of incongruence or distress. “I feel more distress around how people view me identity-wise, and less around how I view my own physical body.” This sentiment was repeated by another youth, “I don’t feel any dysphoria about my body and stuff. I definitely feel like, um, kind of like moderate dysphoria about the way people view me and stuff.” Multiple youth in our focus groups raised the possibility that their dysphoria would not exist in a society with a more diverse and flexible construct of gender. One participant confirmed, “Being able to pass really helps my dysphoria.”
Thinking critically about gender as a social construct led many participants to view dysphoria as a sociocultural problem.
I think because it is such a different broad spectrum of things, what everyone wants simply is to be perceived as the way that they are. And when they can’t do that because of like the way that society is structured, that gives you physical discomfort.
Youth broadened their understanding of dysphoria to shift the burden of pathology to society at large.
While this understanding did not save participants from experiencing dysphoria, it helped to contextualize it.
And relating it to gender is weird because part of me wants to say, like bodies aren’t related to gender, gender is a social construct. But I still had this, you know, very intense feeling whenever I looked at myself in the mirror and I just couldn’t stand it. [. . .] And I think so many people focus on it being a personal thing because they don’t want to confront the transphobia in our society that is inherent.
Dysphoria, in this context, seems a natural consequence of existing within a cis-normative, transphobic society.
Theme 4: TGD Youth Include Dysphoria in Adaptive Behaviors to Establish Positive Identity and Find Community
Dysphoria was described by some youth as critical to self-discovery and establishing their identity.
The self-consciousness I thought I had, like the self-conscious I had and I couldn’t put a name to it, came clear that I was really dysphoric about the way my body looked and that, like being more masculine was me and I’m not a tom boy I’m a boy!
For some, dysphoria catalyzed a self-examination that led to self-knowledge youth felt they otherwise may not have developed.
I’ve been trans for 18 years, um, and I’ve gone through a lot of processes. And I feel like I have come to terms with myself and I am so happy with who I am. And I am so aware of who I am and my identity. And I feel like lots of cis people don’t spend that much time thinking about who they are. If that makes sense.
Ultimately some youth articulated an ability to find gratitude for dysphoria and its role in their identity development.
So, you know, after surgery, best thing that’s ever happened to me. I feel so much happier, so much more comfortable. And that’s the awesome part about dysphoria—thank you, thank you—body dysmorphia. I think the other thing is, is like, dysphoria can be cured. So that’s just my experience with dysphoria.
These testimonies suggest that for some, dysphoria aided self-discovery and positive identity development.
An important component of positive identity formation is community. The unique experience of gender dysphoria makes it a powerful means of connecting to and identifying with members of the TGD community. One youth described thinking their dysphoria was part of typical puberty until meeting a trans person:
I kept convincing myself I could make steps towards finally feeling comfortable. . .once I get my period, I’m finally gonna feel comfortable in my body. I didn’t realize it was the opposite until I met another trans guy like my age. . . .Because I knew that trans people existed but I didn’t know it was an option for me until I met someone else. And they’re now my best friend.
Meeting and connecting with members of the trans community provided this youth with clarity about dysphoria and ultimately gender. Those connections can alleviate some cisgenderism and provide a safe place to heal; “It’s like this whole thing. We’re all there for each other ‘cause we all get it. It’s cool to have that support.” In fact, multiple youth credited relationships with other TGD youth for saving their lives.
The closest friends I have too, are friends I’ve made because I transitioned. Some, of the best friends I have, are trans and nonbinary and like queer, and I would never have made those friends, or made my transition, or be alive without them.
Gender euphoria was also mentioned in focus groups as serving a similar function in recognizing and building community and self-identity.
Youth also reflected out to future generations of transgender youth and were able to contextualize their own struggles as being in service to those future generations.
I’m thinking about the next generation of queer and trans youth and stuff. And how I can take like what I’ve gone through, with even like the slightest discomforts that I’ve ever felt, and try to like make a space and community like however small or broad that is, for them to even just lift that a little bit off their shoulders.
Discussion
In this study, we found that TGD adolescents referred to gender dysphoria in a variety of ways (e.g., clinically, colloquially, and abstractly). Our analysis identified four themes which describe how youth (1) understand gender dysphoria as a clinical diagnosis while (2) broadening it to fit their lived-experiences and (3) developing an understanding of it as an interpersonal experience of stigma which can help to (4) establish a positive self- and community-identity.
While qualitative work with TGD teens has been done, none that we are aware of has documented how these adolescents understand and use the term gender dysphoria, or if they feel impacted by the conflation of their identity with a disorder. Our findings suggest pathologizing TGD teens’ experiences of gender, through the medicalization of “gender dysphoria” as a mental health condition, contributes to structural, interpersonal, and internalized stigma (White Hughto et al., 2015). Prior research suggests stigma and minority stress significantly contribute to adverse health outcomes including violence, depression, anxiety, shame and self-hatred, suicide risk, and limits socioeconomic opportunities (Askevis-Leherpeux et al., 2019; Chodzen et al., 2019; Cooper et al., 2020; Hendricks & Testa, 2012; White Hughto et al., 2015). Thus, developing specific diagnostic terminology that is distinct from language already used broadly within and outside TGD communities may help alleviate stigma and subsequent health disparities.
However, in the United States, and many other places in the world, a medical diagnosis of dysphoria remains necessary to access gender affirming care. As one youth in our study pointed out, a diagnosis can be critical for nonbinary teens who may not fit some providers’ binary expectations of gender as they relate to medical transition. Indeed, there is a long history of medical gate-keeping obstructing trans self-determination (Velocci, 2021). Alongside efforts to depathologize TGD experiences of dysphoria, more work is needed to align policy and medical practices with the most current recommendations for gender affirming care and to recognize that clinical distress may not be experienced by all TGD individuals requiring affirming treatment or ongoing care (Askevis-Leherpeux et al., 2019; Coleman et al., 2022).
Rather than describing all gender dysphoria as a psychiatric health condition, the adolescents in our study describe experiencing some gender dysphoria as a stressor. In line with the constructs posited in the Minority Stress Model (Meyer, 2003), participants indicated instances of internalized transphobia and expectations of interpersonal and structural discrimination when describing their dysphoria. Hendricks and Testa (2012) assert that the stressors unique to gender minority status relate to mental health problems. Specifically, non-affirmation by others of one’s internal sense of gender (Testa et al., 2015) and the invalidation of an identity as “ not real,” particularly for genderqueer individuals (Johnson et al., 2020; Lefevor et al., 2019). The Minority Stress Model helps to explain why TGD adolescents are more likely to have mental health problems (Chodzen et al., 2019). Rather than being indicative of a mental disorder, gender-related distress described by these youth could be a reasonable response to minority stress, stigma, and the pervasiveness of cisgenderism - whether triggered by what Rood et al. (2016) describe as a “frequent and salient internal stressor” or by omnipresent environmental/social reminders. Indeed, the DSM-5 is explicit in stating that a mental disorder is neither an expected response to an event, nor a dissidence with society (American Psychiatric Association, 2013).
Consistent with what has previously been reported for transgender adults and is now acknowledged in the DSM-5 itself, not all transgender people experience psychological distress (Askevis-Leherpeux et al., 2019; Campbell et al., 2018; Robles et al., 2016). Further, for those who do, it can be rooted in external factors (e.g., stigma, invalidation). Previous qualitative research has described gender dysphoria in youth as a complex, multidimensional construct and an individualized experience that is often mediated by social norms and relational dynamics (Jessen, Haraldsen, et al., 2021; Jessen, Waehre, et al., 2021). Many youth in our focus groups identified society and interpersonal interactions as the source of their dysphoria. This is consistent with the conclusions of Cooper et al.’s systemic review and meta-analysis of transgender adult experiences, which identifies a need to better understand the contribution of social environment to gender dysphoria (Cooper et al., 2020).
Meadow (2018a) asserts that while gender affirming treatment has undoubtedly benefited transgender individuals, the medical and research communities have “exert[ed] their own normalizing pressures to order, taxonomize, and measure gender transgressions.” Indeed, while we understand gender to be an internal sense of oneself, gender interrelates with institutions (Meadow, 2018b). Our findings suggest that when medicalized language is used to understand and explain an individual’s experience of themselves and their environment, it can negatively impact their social and emotional well-being and reinforce stigma.
Significant clinical distress is experienced by some TGD people, including some of the participants in our study. These participants understand the clinical significance of their dysphoria. However, they also reject transness as a disorder and are dealing with minority stigma. Thus, they expressed conflicting desires to acknowledge and reduce their dysphoria, while simultaneously refusing to accept that their identity necessitates a distress that is associated with bias and harassment perpetrated by others. As Davy and Toze (2018) assert—“This frequent and diverse usage of “gender dysphoria,” and the application of the concept to populations who may neither meet diagnostic criteria nor experience distress may potentially undermine the stated intention of the APA that the new diagnosis of GD would reduce pathologization.” We observed this in how youth used gender dysphoria to understand themselves and express their experiences.
TGD teens in our study demonstrated a varied use of the term “gender dysphoria” that both reflected and rejected the medicalization of dysphoria, emphasized dysphoria as an interpersonal experience of stigma, and utilized dysphoria as a catalyst to develop positive identity and build community. Though adolescence is universally a time of increased pressures and a search for identity, our analyses show how TGD youth face unique challenges in having to grapple with a stigmatized, minoritized identity—specifically one conflated with a mental disorder.
Limitations
Participants in these focus groups were largely recruited from gender and sexual minority community organizations and all required parent permission to participate. These youth therefore, speak from an experience of having at least started to socially transition, have found community support, and have at least one supportive parent/guardian. It is unclear how this research would look different in youth who are unable to socially transition or are isolated. Other limitations include a lack of racial and ethnic diversity, as well as a minority of female/trans feminine participants. Trans feminine youth may engage with the term dysphoria in different ways than trans masculine youth, and their perspectives are a critical piece that is missing from this study. Additionally, participants were from primarily rural communities in the northeastern United States. Finally, because only audio transcripts were available and youth did not identify themselves each time they spoke, we were unable to attribute quotes to specific individuals.
Conclusion
In this study, we assessed the use of the term dysphoria by TGD adolescents when discussing their experiences of gender. We found that youth understand the clinical definition and experience harm by its use to pathologize their identity and lived experiences. Some youth felt invalidated and prohibited from gender affirming care because of cis-normative assumptions associated with dysphoria; leading them to broaden the term to include benign incongruence as well as to reflect nonbinary experiences. For some youth, dysphoria was primarily interpersonal—the result of society’s discomfort rather than their own. The findings of this qualitative study highlight the harm and limitations inherent in using pathologizing language as identity language. However, through rescripting and self-definition, TGD youth exercise personal agency and reject stigma.
Footnotes
Acknowledgements
We would like to thank the youth for sharing their experiences, without whom this work would not be possible. Thank you to A. Evan Eyler, M.D., MPH for contributions to the conceptualization and analysis of this work. Thanks also to Masha Ivanova, PhD; Kara DeLeonardis Kraus, LICSW; and Hannah Loso, MS for their work on the primary study.
Authors’ Contributions
SLD: conceptualization (equal), data curation (lead), formal analysis (equal), investigation (equal), project administration (lead), writing—original draft (lead), writing—review and editing (equal). MMJ: conceptualization (equal), formal analysis (equal), investigation (equal), methodology (lead), writing—review and editing (equal). JA: conceptualization (supporting), writing—review and editing (equal). ASP: conceptualization (supporting), funding acquisition (lead), investigation (equal), supervision (lead), writing—review and editing (equal).
Data Availability Statement
Data sharing is not available for this article as the datasets include qualitative focus group discussions that contain PII and other potential identifying information from the participants. To maintain participant confidentiality and privacy, these data are not publicly available.
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position or views of the funders. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Institute on Drug Abuse under award number U24DA041147
