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. Author manuscript; available in PMC: 2022 Feb 14.
Published in final edited form as: J Occup Environ Med. 2021 Jan 1;63(1):38–43. doi: 10.1097/JOM.0000000000002065

Menstrual Cycle Patterns and Irregularities in Hired Latinx Child Farmworkers

Rebecca R Varnell 1, Taylor J Arnold 2, Sara A Quandt 3, Jennifer W Talton 4, Haiying Chen 4, Christopher M Miles 2, Stephanie S Daniel 2, Joanne C Sandberg 2, Kim A Anderson 5, Thomas A Arcury 2
PMCID: PMC8842072  NIHMSID: NIHMS1775191  PMID: 33105405

Abstract

Purpose:

This study identifies the menstrual cycle irregularities of Latinx child and adolescent farmworkers.

Methods:

Child and adolescent farmworkers aged 13-20 years completed questionnaires about menstrual cycle patterns in 2019, and wore silicone passive collection wristbands for pesticide detection in 2018. Menstrual cycle irregularities were determined from the American College of Obstetricians and Gynecologists committee opinion.

Results:

Half of participants experienced any menstrual cycle irregularity; the most frequent irregularities were cycle length (38.6%) and having gone 90 days or more without a menstrual period (20.4%). Pesticides were detected in 92.9% of the wristbands; most participants were exposed to an endocrine disrupting chemical (EDC) pesticide.

Conclusion:

Half of Latinx children and adolescents hired farmworkers experience irregular menstrual cycles, and most are exposed to EDCs. Inclusion of occupational and menstrual histories in child and adolescent medical visits is critical.

Keywords: adolescent, agriculture, hormones, menstrual cycle, pesticides, endocrine disrupting chemicals, farmworkers

Children and adolescents hired as farmworkers are exposed to pesticides, and many report limited or no safety training.1 A subset of these pesticides falls into the category of endocrine disrupting chemicals (EDCs), compounds known to affect the endocrine system on multiple levels.2,3 In animal models, peripubertal exposure to EDCs caused aberrant gonadal development, decreased luteinizing hormone levels, and irregular timing of puberty.4,5 In humans, childhood and peripubertal exposure to EDCs has similarly been associated with irregular age at menarche6,7 and menstrual cycle patterns.8 The association between EDCs and observed endocrine disturbances raises concerns for the effects of pesticide exposure on children and adolescents hired as farmworkers.

Current Federal regulations allow children as young as 10 years to be hired legally to work on farms.9 Some states have implemented regulations that impose stricter limits on the ages of children who can work on farms, but most adhere to the Federal regulations. Though children and adolescents can legally work on farms, limited research has examined the work exposures of these child and adolescent farmworkers. Interviews with 130 child and adolescent farmworkers in Washington’s Yakima Valley revealed that only 53% had received some kind of job safety training that included information about pesticide exposure and protection.10 Interviews with migrant adolescent farmworkers in Oregon indicated that though 21.6% of respondents reported mixing or applying chemicals as part of their job, only one-third received pesticide safety training.11 For the current study, at baseline, just over one quarter (26%) of the child and adolescent farmworkers reported ever having received pesticide safety training.12 Even if not working on farms, children and adolescents in farmworker communities face a considerable burden of pesticide exposure due to agricultural spray drift, parental transfer of pesticides from the workplace, and direct application of pesticides in and around the home.13 Analysis of silicone wristbands worn by 97 Latina adolescents in the Salinas Valley, California, showed that living within 100m of active agricultural fields was associated with higher odds of detecting certain pyrethroids and organochlorides on wristbands.14

The effects of EDC exposure on menstrual cycle characteristics have been documented in adults, revealing that exposure to certain EDCs is associated with longer and more irregular menstrual cycles. An analysis of 2,314 women living throughout the United States revealed that serum levels of organochloride pollutants were associated with increased length and irregularity of menstrual cycles.15 Similarly, a prospective cohort study of women living adjacent to Lakes Erie and Ontario found an association between organochlorine pollutant levels in urine and longer menstrual cycles.16 Women who lived in agricultural communities where the herbicide atrazine was used extensively were more likely to report irregular menstrual cycles and more than 6 weeks between periods than those living in comparable communities where atrazine was used sparingly.17 In a cross-sectional study of 3,103 women ages 21-40 years living on farms in Iowa and North Carolina, women who reported ever mixing or applying pesticides had increased odds of experiencing long cycles, missed periods, and intermenstrual bleeding compared with women who had never mixed or applied pesticides.18

Menstrual cycle irregularities in adolescence may indicate endocrine dysregulation and other underlying health concerns.19 Although menstrual cycle patterns are considered a barometer of reproductive and overall health, clinical evaluation in this population can be challenging. The body of literature describing menstrual patterns in adolescents is relatively old, and there is a lack of scientific consensus about the physiology of early menstruation. In an effort to establish clinical consensus, the American College of Obstetricians and Gynecologists (ACOG) published a committee opinion in 2015 titled “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign,” which sets parameters for expected adolescent menstruation and indications for follow-up.19 Based on three large studies of menstrual cycle trends during adolescence,20–22 ACOG reported the median age at menarche as 12.43 years, and found that by 15 years of age, 98% of adolescents will have had their first menstrual period. Most females bleed for 2-7 days during their first year of menses and will require 3-6 pads or tampons per day. Ninety percent of cycles will be within the range of 21-45 days, and cycles longer than 90 days represent the 95th percentile for length. These standards challenge the belief that an immature hypothalamic-pituitary-gonadal (HPG) axis can explain almost any irregularity in menstruation, and encourage providers to evaluate critically patterns that fall outside of them.

The aims of this paper are to describe the menstrual cycle patterns in adolescent farmworkers exposed to pesticides in North Carolina, compare their menstrual cycle patterns to normative guidelines provided by ACOG, and examine associations between menstrual cycle irregularities and demographic and work factors. Currently, no literature exists that describes the menstrual cycles of adolescent farmworkers. The known exposure of farmworker children and adolescents to EDCs during critical developmental years raises important questions about the effects of these compounds on the reproductive system.

Methods

The Hired Child Farmworker Study is a longitudinal community-based participatory research study conducted in North Carolina by investigators at Wake Forest School of Medicine, Student Action with Farmworkers, and East Carolina University. The study began with a 2017 baseline survey of 202 child farmworkers, including 76 females. Clinical examinations and follow-up survey interviews were conducted in 2018 and 2019. The Wake Forest School of Medicine Institutional Review Board approved the research protocol and procedures.

Participants

At recruitment, participants: (1) were aged 10 to 17 years; (2) self-identified as Latinx; (3) were employed to do farm work in the prior three months; and (4) were fluent in Spanish or English. Study design and recruitment strategies are described elsewhere.23 Study staff obtained parental permission and child assent for all study procedures at baseline. To maximize retention in 2018 and 2019, project staff contacted participants throughout the year with reminders of upcoming study procedures.

In 2019, 53 females completed the follow-up clinic questionnaire and examination. Three participants ages 13, 14, and 15 indicated that they had not had a menstrual period, and 2 participants ages 16 and 17 refused to answer. Four participants who reported using a hormonal contraceptive (oral contraceptives, etonogestrel subdermal implant, levonorgestrel intrauterine device) in the previous 12 months were excluded from analysis. The remaining 44 females are included in this analysis. These participants all indicated having had at least one menstrual period and denied using hormonal contraceptives in the previous 12 months.

Data Collection

The primary data for this analysis are from the clinical questionnaire and examination portion of the 2019 follow-up (ages 13-20). At the data collection clinics, participants completed interviewer-administered questionnaires, spirometry tests, and musculoskeletal examinations, and their height and weight were measured. Clinics were held on nine Sundays in different locations throughout North Carolina based on proximity to where participants lived with multiple dates in high-density locations. The majority of clinics were held in schools or community colleges. Transportation to the clinic was provided for participants as needed. Participants attending a clinic received a $50 incentive.

Interview questions related to menstrual cycle characteristics were developed based on the ACOG committee opinion paper19 outlining menstrual cycle patterns and indications for follow-up in the adolescent population. Interviews were conducted in private interview stations by female bilingual interviewers with knowledge of local farmworker communities and training that included sensitivity to the interview content. All interviewers completed CITI Research Ethics and Compliance Training. The interviews were conducted in English or Spanish depending on participant preference. For a small number of participants who were unable to attend a clinic, interviewers completed the clinic interview either in participants’ homes or via telephone.

In 2018, silicone wristband passive sampling devices were distributed to participants to be worn for one day. Analysis of environmental pesticide exposure using these devices has been described elsewhere.24 In brief, to quantify the presence of a pesticide on a given wristband, concentrations of that compound are increased until reaching equilibrium with the sampler. Wristbands were analyzed at the Food Safety and Environmental Stewardship Laboratory at Oregon State University.

Measures

The measures included in this analysis were: (1) personal characteristics; (2) pesticide exposure; and (3) menstrual characteristics. Personal characteristics included age (in the categories 13-15, 16-18, 19-20 years); gynecologic age calculated as the difference between chronological age and age at menarche (in the categories 1-2, 3-6, 7-11 years); worked in farm work in 2019 (dichotomous); number of years worked in farm work from 2017-2019; number of years worked in farm work in lifetime (in the categories 1, 2-3, 4 or more). For the 43 participants ages 13-19, BMI was calculated using the formula: weight (lb) / [height (in)]2 x 703, which was then converted to BMI-for-age percentile using the CDC BMI-for-age growth chart for girls.25,26 Weight status was classified as <5th BMI weight for age percentile being underweight, 5th - <85th percentile being normal weight, 85th - <95th percentile being overweight, and ≥95th percentile being obese. For the 20 year-old participant, raw BMI was calculated using the formula: weight (lb) / [height (in)]2 x 703 [27]. Weight status category was defined as <18.5 being underweight, 18.5-<26 being normal weight, 25-<30 being overweight, and ≥30 being obese.

Dichotomous measures of pesticide exposure include the detection in the silicone wristband of any pyrethroid, organochlorine, and organophosphate pesticide. The detection of any pesticide from the 14 classes included in the laboratory analysis was a dichotomous measure. Any detection of at least one pesticide out of the 14 total classes measured was considered positive.24

Menstrual characteristics included age at menarche (in the categories 9-10, 11-15, >15 years); length of menstrual periods (<3 days, 3-7 days, 8-14 days); length of menstrual cycle (<21 days, 21-45 days, >45 days, too irregular to tell); number of pads/tampons per day (1-2, 3-6). Other menstrual characteristics included the dichotomous measures of bleeding between menstrual periods and ever having gone 90 days or more without a menstrual period, excluding times when pregnant or breastfeeding.

Menstrual cycle irregularities as defined by ACOG were age at menarche greater than 15 years; length of menstrual period more than 7 days; cycles that occur less frequently than 21 days, more frequently than every 45 days, or are too irregular to tell; any menstrual periods occurring 90 days apart or more; and requiring the use of more than 6 pads or tampons per day. The measure of any menstrual irregularity (none, at least one) was also defined. Though early age at menarche was not defined by ACOG as a parameter of irregular menstruation, age at menarche less than 11 years was also noted.

Analysis

Frequencies and percents were calculated for personal characteristics, pesticide exposure, and menstrual characteristics and irregularities. Associations between personal characteristics and any irregularity were examined using Chi-Square or Fisher’s exact test as appropriate. All analyses were performed using SAS v. 9.4 (SAS Institute, Cary, NC) and p-values of < .05 were considered statistically significant.

Results

Personal Characteristics

The participants were between 13 and 20 years old, and gynecologic ages ranged from 1-11 years (Table 1). More than half (59.5%) were overweight or obese. All of the participants worked in farm work in 2017 and almost half (47.7%) also worked in farm work in 2019. Total years in farm work ranged from one year (29.6%) to 4 or more (45.4%).

Table 1.

Personal characteristics of Latinx female farmworkers not using hormonal birth control who reported at least one menstrual period, 2019 (n=44)

Personal characteristics n (%)
Age (in years)
  13-15 11 (25.0)
  16-18 20 (45.5)
  19-20 13 (29.5)
Gynecologic age (in years)
  1-2 5 (11.4)
  3-6 27 (61.4)
  7-11 12 (27.3)
Weight Status Categorya
  Underweight 1 (2.4)
  Normal Weight 16 (38.1)
  Overweight 14 (33.3)
  Obese 11 (26.2)
Worked in Farm Work in 2019
  Yes 21 (47.7)
  No 23 (52.3)
Number Years Worked in Farm Work, 2017-2019
  1 20 (45.5)
  2 4 (9.1)
  3 20 (45.5)
Number Years Worked in Farm Work, Lifetime
  1 13 (29.6)
  2-3 11 (25.0)
  4 or more 20 (45.4)
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a

2 missing

Pesticide Exposure

The most commonly detected of the 14 pesticide pesticides class were pyrethroids, (71.4%), followed by organochlorines (57.1%), and organophosphates (45.2%) (Table 2). At least one pesticide was detected for 92.9% of the participants.

Table 2.

2018 pesticide exposure of Latinx female farmworkers

Pesticide exposure n (%)
Pesticide Class
   Pyrethroids 30 (71.4)
   Organochlorines 24 (57.1)
   Organophosphates 19 (45.2)
At least one pesticide detection 39 (92.9)
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Menstrual Characteristics and Irregularities

Most (75%) of the participants had their first menstrual period between ages 11 and 15 while 10 participants (22.7%) were between 9 and 10 years and 1 participant (2.3%) was older than 15 years (Table 3). Over 90% of participants reported a menstrual period that lasted between 3 and 7 days, and one participant (2.3%) reported a period lasting between 8-14 days. While most (61.4%) of the participants reported length of menstrual cycle to be 21-45 days, 9.1% had a menstrual cycle length less than 21 days and 4.6% had a cycle length more than 45 days. One-quarter of participants reported that their cycle length was too irregular to tell. Most participants (90.9%) reported using between 3-6 pads or tampons per day. 18.2% reported bleeding between menstrual periods, and 20.4% reported having gone 90 days or more without a menstrual period, excluding any times they were pregnant or breastfeeding.

Table 3.

General menstrual characteristics and menstrual irregularities

Menstrual characteristics and menstrual irregularities n (%)
Age at menarche
  9-10 years 10 (22.7)
  11-15 years 33 (75.0)
  >15 years 1 (2.3)
Length of menstrual periods
  < 3 days 3 (6.8)
  3-7 days 40 (90.9)
  8-14 days 1 (2.3)
Length of menstrual cycle
  <21 days 4 (9.1)
  21-45 days 27 (61.4)
  > 45 days 2 (4.6)
  Too irregular to tell 11 (25.0)
Number of pads/tampons per day
  1-2 4 (9.1)
  3-6 40 (90.9)
Bleeding between menstrual periods
  Yes 8 (18.2)
  No 36 (81.8)
90 days or more without a menstrual period
  Yes 9 (20.4)
  No 35 (79.6)
Irregularities
  Age at menarche >15 years 1 (2.3)
  Length of menstrual periods >7 days 1 (2.3)
  Irregular length of cycle (<21 days or > 45 days or too irregular) 17 (38.6)
  90 days or more without a menstrual period 9 (20.4)
  >6 pads/tampons used per day 0
Any Menstrual Irregularity
  None 22 (50.0)
  At least one 22 (50.0)
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Half of the participants had at least one menstrual irregularity; 2.3% had an irregular age at menarche, 2.3% had an irregular menstrual period length, 38.6% had an irregular menstrual cycle length, and 20.4% had ever gone 90 days or more without a menstrual period. No participants used an excessive number of pads or tampons per day. Early age at menarche was not included as a menstrual irregularity per ACOG standards; however, 22.7% had early menarche defined as less than 11 years.

Associations of Menstrual Cycle Irregularities with Personal Characteristics

Age was the only personal characteristic associated with menstrual cycle irregularities; younger participants were less likely to have any irregularity (Table 4). Among those with any irregularity, 13.6% were 13-15 years old, 40.9% were 16-18 years old and 45.5% were 19-20 years old; whereas 36.4%, 50%, and 13.6% did not have any irregularities for the respective age categories. Gynecologic age, weight status category, and number of years doing farm work were not associated with menstrual irregularities.

Table 4:

Association of personal characteristics with any menstrual irregularity

Personal Characteristics Any irregularity
Yes
n = 22		 No
n = 22
n (%) n (%)
Age
 13-15 3 (13.6) 8 (36.4)a
 16-18 9 (40.9) 11 (50.0)
 19-20 10 (45.5) 3 (13.6)
Gynecologic age
 1-2 1 (4.6) 4 (18.2)
 3-6 12 (54.5) 15 (68.2)
 7-11 9 (40.9) 3 (13.6)
Weight Status Categoryb
 Normal weight 9 (40.9) 7 (36.8)
 Overweight 6 (27.3) 8 (42.1)
 Obese 7 (31.8) 4 (21.1)
Number years doing farm work, 2017-2019
 1 10 (45.5) 10 (45.5)
 2-3 12 (54.5) 12 (54.5)
Number Years Worked in Farm Work, Lifetime
 1 6 (27.3) 7 (31.8)
 2-3 6 (27.3) 5 (22.7)
 4 or more 10 (45.4) 10 (45.4)
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a

p=0.044

b

excluding 1 underweight participant and 2 additional with missing weight status; n = 41

Discussion

Participants in this study are exposed to pesticides through working on farms and living in farmworker communities. Results from a previous study of hired child and adolescent farmworkers in North Carolina revealed that only 8% had ever received pesticide training.1 For the current study, at baseline, just over one quarter (26%) of the child and adolescent farmworkers reported ever having received pesticide training.12 Living in a farmworker community alone carries a considerable burden of pesticide exposure through agricultural spray drift, parental transfer of pesticides from the workplace, and direct application of pesticides in and around the home.13 Analysis of silicone wristbands worn for one day in 2018 by 42 of the 44 participants included in this study indicated that at least one pesticide was detected on 92.9% of samples. The most commonly detected pesticides were pyrethroids, organochlorines, and organophosphates. Each of these compounds is an EDC, and their endocrine effects have been well described in the literature.28

Wristband data indicates that participants are exposed to EDCs which are known to cause endocrine disturbances and menstrual irregularities. The most frequently reported menstrual irregularities were cycle length (38.6%) and having gone 90 days or more without a period (20.4%). The proportion of participants who fell outside the parameters of regular menstrual cycle length (13.7%) was similar to the expected proportion (10%) based on the ACOG guidelines. However, an additional 25% reported their cycle was “too irregular to tell.” Though some degree of irregularity is anticipated due to HPG axis immaturity, the 2017-2018 National Health and Examination Nutrition Survey (NHANES) reported that only 3% of participants aged 13-20 answered “no” when asked if they had regular periods in the last 12 months.29 Additionally, 20.4% of participants in our study of farmworkers reported having gone 90 days or more without a menstrual cycle, which ACOG cites as the 95th percentile of menstrual cycle length, even in the first year after menarche. Taken together, participants in this study had a higher proportion of irregular menstrual cycles with long intervals between periods than would be expected based on the ACOG guidelines and analysis of NHANES data. In animal models, EDCs can decrease the amount of luteinizing hormone released, resulting in delayed or absent ovulation.2 Anovulation or irregular ovulation may explain the long stretches without a menstrual period and irregular cycle lengths.

The association between age and menstrual irregularities may indicate the effects of continuous lifetime pesticide exposure. In this study, older age was the only demographic category associated with a higher prevalence of menstrual irregularities (p<0.05). However, gynecologic age (current age – age at menarche), was not associated with increased irregularities. This trend suggests that the age-related increase in irregularities was not solely a reflection of increased number of menstrual cycles experienced to date, but perhaps reflects a higher total lifetime pesticide exposure.

The high proportion of participants with irregular menstrual cycle lengths with long intervals between menstrual periods is consistent with previous studies performed on populations exposed to EDCs in non-agricultural contexts.15–17 Though no studies investigating menstrual cycle characteristics in hired adolescent farmworkers exist, living near agricultural fields has been associated with irregular cycle length and intermenstrual bleeding in adolescents.8 In adults, exposure to EDCs through farm work and living on or near farms has been associated with long, irregular cycles.17–18 These findings support the association between EDC exposure and the menstrual cycle irregularities seen among participants in this study.

Most (97.7%) participants had menarche by 15 years, which is consistent with the ACOG guidelines. Though not considered a menstrual irregularity by this ACOG committee opinion, the relatively high proportion (22.7%) of participants experiencing early menarche is of interest. The committee opinion sets the parameters for normal age at menarche based on an analysis of NHANES data from 1988-1994. This study shows that less than 10% of adolescents began menstruating before age 11.30 NHANES data from 2015-2018 for adolescents aged 13-20 similarly report that only 13.65% began menstruating before 11 years.31 In comparison, over one-fifth (22.7%) of participants in our study began menstruating before age 11. While EDCs have consistently been associated with increased menstrual cycle length and missed menstrual periods, the association with age at menarche is less clear. Because the effects of different EDCs are varied, EDC exposure has been associated with both early and delayed puberty.6,7 However, early age at menarche has a consistent association with such risk as increased BMI and chronic exposure to physical and psychosocial stressors.32,33 Thus, the high proportion of participants reaching menarche before 11 years may correlate with other markers of health in this population.

Beyond pesticide exposure, child and adolescent farmworkers face threats to their physical and mental health related to healthcare access, food insecurity, and socioeconomic status.34 These factors can have a large impact on the HPG axis and each has been associated with menstrual cycle irregularities in adolescents and adults.35,36 Beyond being farmworkers, these study participants hold multiple intersecting identities. All are children of Latinx immigrants in rural North Carolina, are female, identify as Hispanic or Latinx, and speak Spanish in the home. While considering the exposure risk to EDCs in this population is critical, it is also necessary to recognize the complexity of factors influencing the menstrual cycle.

This study has several significant limitations. The sample size is small (n=44) and the sample population is demographically homogenous. Menstrual cycle characteristics were self-reported and thus may not be accurate. Additionally, wristbands were only worn for one day, and pesticide exposure as determined from this single day cannot be reasonably correlated with menstrual cycle irregularities for individual participants. The data from the wristbands do however offer a snapshot of lifetime pesticide exposure for participants who both live and work in farmworker communities. Data were collected in the third year of the Hired Child Farmworkers Study, and 28 female participants were unable to attend the clinic where these data were collected or were lost to follow-up. Sex assigned at birth and gender identity were not included as questions in this survey, and interviewers used personal judgment to determine when to ask about menstrual cycle characteristics.

Another limitation of this study is the lack of menstrual cycle comparison data from a population similar to this study population. ACOG parameters of regular menstrual cycle patterns in adolescents are based on data collected between 1971 and 1994; the racial and ethnic identification for the populations used by ACOG differed from those of the participants in this study. In order to develop meaningful clinical guidelines for this population, more research is needed that includes a diversity of racial and ethnic identification.

Conclusions

Participants in this study had a higher proportion of long and irregular menstrual cycles with long intervals between menstrual periods than expected based on the ACOG guidelines. These findings raise concerns for the physiologic impact of EDC exposure and highlights the need for comprehensive menstrual and occupational histories in pediatric patients. Detecting menstrual cycle irregularities in adolescence may shed light onto underlying health issues and predict future health concerns.37 Pesticide exposure in adolescence may also have future health consequences that are yet to be elucidated. For example, exposure to the pesticide p, p’ -DDT during childhood and early adolescence has been associated with the development of breast cancer in adulthood.38 While this pesticide was banned in the United States, other EDCs may similarly impact the developing body in ways not initially evident.

Early education and communication about menstruation can reduce anxiety, and routine medical visits offer a safe and appropriate space for these conversations.39 In order to understand the etiology of menstrual cycle irregularities, obtaining a complete social history is critical. Because children and adolescents in farmworker communities may have few opportunities for clinical evaluation due to healthcare access barriers,40 healthcare providers should routinely include occupational and menstrual histories into pediatric visits when applicable. Given the potentially grave consequences of pesticide exposure in this population and limited understanding of the effects of such exposures on the developing body, more research focused on child and adolescent farmworkers is needed.

This study is the first description and analysis of menstrual cycle characteristics in child and adolescent farmworkers. Results show this population to have a higher rate of menstrual cycle irregularities than expected, based on American College of Obstetricians and Gynecologists guidelines. Exposure to endocrine disrupting pesticides may explain these findings.

Acknowledgments:

The authors are grateful for the comments of Robert N. Taylor, MD, PhD, on an earlier draft of this paper. The authors appreciate the support and participation of Student Action with Farmworkers’ Levante Leadership Institute co-investigators and members who serve as the youth advisory committee, and the members of the professional advisory committee. We also appreciate the valuable contributions of our community field interviewers in carrying out participant recruitment and data collection. We especially thank the children who participated in this study.

Funding:

This research was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (R01 HD084420). The Institute had no involvement in the study conduct, in writing the paper, or in the decision to submit it for publication.

Footnotes

Disclosure Statement: Thomas A. Arcury, PhD, reports that in the 36 months prior to submission of this paper that he had financial relationships for consultation with Meharry Medical College (Nashville, TN), and for expert testimony with the Southern Poverty Law Center.

Rebecca R. Varnell, BS, reports no conflicts of interest.

Taylor J. Arnold, MA, reports no conflicts of interest.

Sara A. Quandt, PhD, reports no conflicts of interest.

Jennifer W. Talton, MS, reports no conflicts of interest.

Haiying Chen, MD, PhD, reports no conflicts of interest.

Christopher M. Miles, MD, reports no conflicts of interest.

Stephanie S. Daniel, PhD, reports no conflicts of interest.

Joanne C. Sandberg, PhD, reports no conflicts of interest.

Kim A. Anderson, PhD, reports no conflicts of interest.

Ethical Considerations & Disclosure: All procedures were approved by the Wake Forest School of Medicine Institutional Review Board. Participants’ parents provided written consent, and child participants provided written assent. The Board approved an exemption to be able to conduct interviews without parental permission among unaccompanied minors, defined as children younger than 18 years of age who had no parent with them in North Carolina.

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