Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions

Sensitive Health Topics With Underserved Patient Populations: Methodological Considerations for Online Focus Group Discussions

Online focus group discussions provide an anonymous environment to assess sensitive, health-related experiences that may be difficult to discuss utilizing traditional face-to-face modalities, particularly for marginalized populations such as female-to-male trans masculine (TM) transgender individuals. This article reviews the history, advantages, and disadvantages of online focus groups, with an emphasis for research about sensitive issues with stigmatized, rare, and/or geographically dispersed patient populations. The article then evaluates the success of online focus group discussions as a case study using data from four asynchronous online focus groups conducted between September 2015 and February 2016 that explored topics related to sexual health care access with U.S. TM adults ( N = 29). The rationale for selecting an asynchronous online methodology is described along with the unique methodological considerations that emerged in developing the study protocol. We conclude by sharing lessons learned, including innovations for maximizing participant engagement and comfort to elicit rich qualitative data.

Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998-1999 to 2015-2016

Data from two studies of transgender women in Los Angeles County that used the same methodology and survey assessment (Study 1: 1998-1999, N = 244; Study 2: 2015-2016, N = 271), compared structural determinants of health, HIV/STI prevalence, HIV risk behaviors, substance use, gender confirmation procedures, and perceived discrimination and harassment/abuse across a 17-year time period. Findings demonstrated that participants in the latter study reported significantly higher access to healthcare insurance and prescription hormones. However, participants in the latter study also reported lower levels of income; and, elevated prevalence of homelessness, HIV and lifetime STIs, receptive condomless anal intercourse with casual partner(s), and reported physical harassment/abuse. Given the timeframe of these results, these findings elucidate specific areas of transgender women's health and risk profiles that improved or worsened across 17 years. While healthcare access has improved, transgender women continue to face significant barriers to good health, indicating the need for increased attention to this population.

Developing Trans-Affirming Health Services in an Underserved Area: An Intersectional Approach

Purpose: Gender-nonconforming patients are at higher risk for medical problems that require prompt medical and mental health intervention. Barriers to healthcare for transgender individuals have been well characterized in the literature, but not in low resource settings. The purpose of this paper is to present the barriers encountered when bringing healthcare to transgender children, adolescents, and adults in a medically underserved, predominantly Hispanic area of the United States. Methods: In this medically underserved area on the U.S.-Mexico border, there is a severe shortage of medical expertise for transgender individuals at both the primary- and specialty-care levels. Further, given the mainly Hispanic population, there is an additional culturally based barrier to obtaining medical care for transgender patients. Results: It is important for academic centers in these regions to collaborate to overcome these barriers through a multidisciplinary approach that includes providing education for medical students and physicians in training and identifying medical providers who are able and willing to provide transgender-competent care adapted to local culture and gender norms. Conclusion: In this manuscript, we will describe the efforts of various groups to address the needs of the transgender community in the region.

Healthcare Mistreatment and Avoidance in Trans Masculine Adults: The Mediating Role of Rejection Sensitivity

Objectives

Given that prior mistreatment can lead to heightened vigilance to and perceptions of future rejection, the present study examined whether this heightened vigilance, known as rejection sensitivity, mediates the association between healthcare mistreatment and healthcare avoidance in trans masculine (TM) adults.

Method

Between 2015 and 2016, 150 TM adults completed a comprehensive survey assessing socio-demographics, sexual health, and healthcare experiences. A 5-item scale assessing participants' sensitivity to rejection in healthcare scenarios was administered and psychometrically evaluated. Structural equation modeling was used to test whether rejection sensitivity in healthcare mediated the relationship between lifetime mistreatment in healthcare and past 12-month healthcare avoidance among TM adults.

Results

Overall, 68% of participants had experienced some form of mistreatment in healthcare in their lifetime and 43% had avoided healthcare in the past 12 months. For 5% of the sample, healthcare avoidance in the past 12 months resulted in a medical emergency. Path analyses revealed that healthcare mistreatment was positively correlated with rejection sensitivity and sensitivity was positively correlated with past 12-month healthcare avoidance. Rejection sensitivity mediated the relationship between mistreatment and healthcare avoidance (all p-values < 0.05).

Conclusion

Rejection sensitivity may contribute to healthcare avoidance among stigmatized TM patients; however, longitudinal research is needed to establish the temporal ordering of these processes. Multilevel interventions to reduce healthcare discrimination and help TM adults cope with the psychological and behavioral consequences of stigma are recommended.

Three-dose HPV vaccine completion among sexual and gender minority young adults at a Boston community health center

BACKGROUND

Disparities in human papillomavirus (HPV) vaccination completion have been noted among sexual and gender minority (SGM) people. Little is known about factors associated with HPV vaccination among SGM people. This study examines factors linked with completion of HPV vaccination among SGM patients.

METHODS

We collected cross-sectional data from electronic health records (EHRs) of SGM patients receiving primary care at a Boston community health center specialized in SGM health. We employed a binomial logistic regression model to identify factors associated with 3-dose HPV vaccine completion.

RESULTS

Patients were 70.3% white, with mean age of 26.3 years (SD = 2.48), 26.9% identifying as gender minorities and 79% as sexual minorities, 48.9% with 4-year college or graduate degrees, 59.4% employed, 65.9% with private insurance, 39.1% living at or below the federal poverty level, and 8.3% living with HIV. Seventy-seven percent of patients who were offered HPV vaccination had completed the series. Factors significantly associated with HPV vaccine completion included: 4-year college or graduate degree (OR: 2.87; 95% CI = 1.26-6.53), completion of primary care appointments (OR: 1.03; 95% CI: 1.01-1.05), Hepatitis A or B vaccine completion (OR: 2.59; 95% CI: 1.2-5.59), and visits for a sexually transmitted infection (STI) screen (OR: 1.22; 95% CI: 1.03-1.43).

CONCLUSION

Vaccine completion was higher among SGM with higher levels of education, Hepatitis A or B vaccination, and completed health visits. These findings highlight potential ways to increase HPV vaccination, such as offering tailored HPV vaccine education, bundling with other vaccines, and incorporating HPV vaccination with STI screenings.

Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents

BACKGROUND

The transgender (trans) population faces multiple barriers in accessing health care, with knowledge deficits of health care providers contributing substantially. Trans patients report having to teach health care professionals about their own health needs. We compared perceptions of trans-care education and training across family medicine, psychiatry, endocrinology, and urology residency training programs at the University of Toronto.

METHODS

We surveyed residents to assess their perceptions of and attitudes towards trans-care, exposure to trans patients, knowledge of trans-specific clinical care, and the state of trans-care education within their training. We used Likert scale data to identify patterns across residency programs. We collected open-ended responses to further explain quantitative findings where appropriate.

RESULTS

Of 556 residents approached, 319 participated (response rate = 57.4%). Nearly all endocrinology and psychiatry residents agreed that trans-care falls within their scope of practice, while only 71% and 50% of family medicine and urology residents did, respectively. Though participants were at different stages of their postgraduate training when surveyed, only 17% of all participants predicted they would feel competent to provide specialty-specific trans-care by the end of their residency and only 12% felt that their training was adequate to care for this population.

CONCLUSION

Though the study revealed a willingness to serve this population, there was a lack of clinical exposure and trans-related teaching within postgraduate curricula resulting in feelings of unpreparedness to meet the health care needs of this underserved population.

Using clinician text notes in electronic medical record data to validate transgender-related diagnosis codes

Objective

Transgender individuals are vulnerable to negative health risks and outcomes, but research remains limited because data sources, such as electronic medical records (EMRs), lack standardized collection of gender identity information. Most EMR do not include the gold standard of self-identified gender identity, but International Classification of Diseases (ICDs) includes diagnostic codes indicating transgender-related clinical services. However, it is unclear if these codes can indicate transgender status. The objective of this study was to determine the extent to which patients' clinician notes in EMR contained transgender-related terms that could corroborate ICD-coded transgender identity.

Methods

Data are from the US Department of Veterans Affairs Corporate Data Warehouse. Transgender patients were defined by the presence of ICD9 and ICD10 codes associated with transgender-related clinical services, and a 3:1 comparison group of nontransgender patients was drawn. Patients' clinician text notes were extracted and searched for transgender-related words and phrases.

Results

Among 7560 patients defined as transgender based on ICD codes, the search algorithm identified 6753 (89.3%) with transgender-related terms. Among 22 072 patients defined as nontransgender without ICD codes, 246 (1.1%) had transgender-related terms; after review, 11 patients were identified as transgender, suggesting a 0.05% false negative rate.

Conclusions

Using ICD-defined transgender status can facilitate health services research when self-identified gender identity data are not available in EMR.

Missed opportunities: are residents prepared to care for transgender patients? A study of family medicine, psychiatry, endocrinology, and urology residents

BACKGROUND

The transgender (trans) population faces multiple barriers in accessing health care, with knowledge deficits of health care providers contributing substantially. Trans patients report having to teach health care professionals about their own health needs. We compared perceptions of trans-care education and training across family medicine, psychiatry, endocrinology, and urology residency training programs at the University of Toronto.

METHODS

We surveyed residents to assess their perceptions of and attitudes towards trans-care, exposure to trans patients, knowledge of trans-specific clinical care, and the state of trans-care education within their training. We used Likert scale data to identify patterns across residency programs. We collected open-ended responses to further explain quantitative findings where appropriate.

RESULTS

Of 556 residents approached, 319 participated (response rate = 57.4%). Nearly all endocrinology and psychiatry residents agreed that trans-care falls within their scope of practice, while only 71% and 50% of family medicine and urology residents did, respectively. Though participants were at different stages of their postgraduate training when surveyed, only 17% of all participants predicted they would feel competent to provide specialty-specific trans-care by the end of their residency and only 12% felt that their training was adequate to care for this population.

CONCLUSION

Though the study revealed a willingness to serve this population, there was a lack of clinical exposure and trans-related teaching within postgraduate curricula resulting in feelings of unpreparedness to meet the health care needs of this underserved population.

Loneliness as a mediator of the relationship between shame and health problems in young people exposed to childhood violence

RATIONALE

Shame related to childhood violence can be detrimental to mental and physical health. Shame may erode social bonds.

OBJECTIVE

In this study we tested whether loneliness is an important pathway between violence-related shame and health problems.

METHOD

Individuals who reported exposure to childhood violence in a telephone interview survey in 2013 (wave one) were re-contacted 12-18 months later (wave two), as part of a more general survey of the Norwegian adult population. In total, 505 adolescent and young adult participants (mean age = 21 years) responded to questions about violence exposure, violence-related shame, loneliness, anxiety/depression symptoms, and somatic health complaints. We used counterfactually based causal mediation analysis within the structural equation modelling framework to test whether loneliness mediated a potential association between shame and health.

RESULTS

Shame had a profound effect on anxiety/depression symptoms and we identified both direct and indirect effects. Loneliness mediated about one third of the relationship between shame and anxiety/depression symptoms. The relationship between shame and somatic health complaints was weaker in total, but this more modest effect largely occurred indirectly through loneliness.

CONCLUSIONS

Our results add to the literature by highlighting the role of loneliness in the relationship between shame and health. Shame may have the potential to break down social connectedness, with a detrimental effect on health. Clinicians may find it helpful to pay close attention to the way shame regulates social interaction. Preventing social isolation and loneliness may promote good health in violence victims.

Embodied disruption: "Sorting out" gender and nonconformity in the doctor's office

Among LGBTQ people, those who are gender nonconforming (GNC) may be at heightened risk of both discrimination and underutilization of healthcare-yet little is known about what happens during healthcare encounters to compel GNC individuals to continue or avoid seeking future care. This study qualitatively examines the healthcare experiences of a racially diverse sample of 34 adult LGBTQ cis women, transgender men, and nonbinary individuals in a metropolitan area of the United States who do not conform to dominant biomedical schemas of sex and gender. GNC individuals experience embodied disruption in medical settings when patients are mis/recognized; providers respond to disruption in ways that further distress patients. Broadly, participants report similar experiences across racial and gender identities, but patients manage disruption somewhat differently depending on their embodied positions to gender norms. This study contributes to literature of stress, stigma, and sex, gender, and sexuality within medicine by illuminating how stigmatizing healthcare interactions deter LGBTQ individuals from seeking healthcare. Findings point to the importance of considering both structural factors and embodied visibility in future research addressing how stigma and discrimination manifest within health settings to disadvantage LGBTQ groups.

Sex with a transgender or gender diverse person among patients attending a sexual health centre in Melbourne, Australia

OBJECTIVES

All males and females attending the Melbourne Sexual Health Centre (MSHC) from August 2017 were asked whether they had had sex with a transgender or gender diverse (TGD) person using computer-assisted self-interviewing (CASI). We aimed to verify the self-reported responses via chart review. The secondary aim of this study was to identify whether having sex with a TGD person was associated with STI risk.

METHODS

This was a retrospective chart analysis of patients visiting MSHC between August and December 2017. Chart review was performed to verify the self-reported responses. Multivariable logistic regression was performed to examine the association between having sex with a TGD person and patients' characteristics and STI risk.

RESULTS

Of the 10 100 male and female consultations, the proportion who reported having sex with a TGD person was 111 (1.0%) and was higher among males (1.3%) than females (0.6%) (p=0.001). After chart review, we could verify 66.9% of the responses, more for males (75.2%) than females (45.2%) (p<0.001). Of the 6822 males, men aged ≥35 years (adjusted OR=2.2; 95% CI 1.1 to 4.1) were more likely to have sex with a TGD person compared with men aged ≤24 years, after adjusting for confounding factors. Sex with a TGD person was not associated with sexual orientation in males. Of the 3278 females, gay and bisexual females had 13.7-fold (95% CI 5.1 to 37.0) higher odds of having sex with a TGD person than heterosexual females. There was no association between chlamydia positivity and sex with a TGD person in both males and females.

CONCLUSION

When a question on TGD partners is asked as part of routine sexual history using CASI, the majority of responses could be verified. TGD partners were most commonly reported among males. These findings underscore the value of asking patients about sex with TGD partners.

Understanding Intersectionality and Resiliency among Transgender Adolescents: Exploring Pathways among Peer Victimization, School Belonging, and Drug Use

Transgender youth experience elevated levels of victimization and may therefore report greater drug use than their cisgender peers, yet little is known about protective factors like school belonging that may mediate this relationship. Further, scant research has explored the experiences of youth at the intersection of transgender identity and youth of color status or low socioeconomic status, especially with respect to these multiple minority statuses’ associations with peer victimization, drug use, and school belonging. Using data from the California Healthy Kids Survey, the current study employs structural equation modeling to explore the relationships among school belonging, peer victimization, and drug use for transgender youth. Findings indicate that school belonging does mediate the pathway between peer victimization and drug use for transgender youth and that although youth of color experience greater victimization, they do not engage in greater drug use than their white transgender peers. Based on these results, those concerned with the healthy futures of transgender youth should advocate for more open and affirming school climates that engender a sense of belonging and treat transgender youth with dignity and fairness.

Creating, reinforcing, and resisting the gender binary: a qualitative study of transgender women's healthcare experiences in sex-segregated jails and prisons

Purpose Incarcerated transgender women often require healthcare to meet their physical-, mental-, and gender transition-related health needs; however, their healthcare experiences in prisons and jails and interactions with correctional healthcare providers are understudied. The paper aims to discuss these issues. Design/methodology/approach In 2015, 20 transgender women who had been incarcerated in the USA within the past five years participated in semi-structured interviews about their healthcare experiences while incarcerated. Findings Participants described an institutional culture in which their feminine identity was not recognized and the ways in which institutional policies acted as a form of structural stigma that created and reinforced the gender binary and restricted access to healthcare. While some participants attributed healthcare barriers to providers' transgender bias, others attributed barriers to providers' limited knowledge or inexperience caring for transgender patients. Whether due to institutional (e.g. sex-segregated prisons, biased culture) or interpersonal factors (e.g. biased or inexperienced providers), insufficient access to physical-, mental-, and gender transition-related healthcare negatively impacted participants' health while incarcerated. Research limitations/implications Findings highlight the need for interventions that target multi-level barriers to care in order to improve incarcerated transgender women's access to quality, gender-affirmative healthcare. Originality/value This study provides first-hand accounts of how multi-level forces serve to reinforce the gender binary and negatively impact the health of incarcerated transgender women. Findings also describe incarcerated transgender women's acts of resistance against institutional and interpersonal efforts to maintain the gender binary and present participant-derived recommendations to improve access to gender affirmative healthcare for incarcerated transgender women.

Epidemiology of HIV, Sexually Transmitted Infections, Viral Hepatitis, and Tuberculosis Among Incarcerated Transgender People: A Case of Limited Data

Transgender people experience a disproportionate burden of human immunodeficiency virus (HIV) and incarceration. Discrimination, victimization, poverty, and poor mental health drive vulnerability to HIV and related infections, as well as risk of arrest, detention, and incarceration. In this paper, we systematically review published data on HIV, sexually transmitted infections, viral hepatitis, and tuberculosis among incarcerated transgender people; describe potential structural determinants of HIV risk and transmission; identify gaps in the literature; and make recommendations for research and interventions to address this neglected population. We found that HIV and related infections among incarcerated transgender people have received little attention in the epidemiologic literature. The limited data available, which date from 1992, demonstrate high prevalence of HIV and sexually transmitted infections in this population internationally. Transgender people who had not had genital surgery were typically placed in jails and prisons corresponding to birth-assigned sex rather than gender identity. Once incarcerated, they routinely faced harassment, physical abuse, and sexual violence from inmates and staff and denial of access to medically necessary gender-affirming therapies. More HIV research with incarcerated transgender populations is urgently needed to inform correctional policy change that centers human rights and structural interventions, such as stigma reduction, pre-arrest diversion, and access to HIV prevention methods and gender-affirming care during incarceration.

Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil

Resumo: Trata-se de um estudo qualitativo, com base na análise de narrativas produzidas por travestis e mulheres transexuais em Salvador, Bahia, Brasil, com o objetivo de analisar suas experiências de estigmatização, descrevendo acontecimentos, atores e contextos que marcam as suas trajetórias de vida, e também compreender a relação entre o estigma e suas performances femininas. As narrativas são provenientes de 19 entrevistas em profundidade realizadas ao longo de um inquérito epidemiológico. Foram orientadas por um roteiro prévio que explorou a produção de narrativas sobre as experiências e modos de vida das travestis e mulheres transexuais na cidade de Salvador. As histórias de vida que emergiram do campo foram transcritas e analisadas sob uma perspectiva teórico-narrativa. Observou-se que muitas travestis e mulheres transexuais apresentaram em suas narrativas a descrição de uma performance de gênero “afeminada”, que é identificada desde à infância por membros da família e da comunidade. Essa performance é apresentada como uma insubordinação ao poder estabelecido pelo sistema jurídico da sociedade heteronormativa. O processo de estigmatização começa a operar quando as expectativas sociais sobre a coerência entre “sexo biológico” e “performance de gênero” são frustradas nas interações sociais, submetendo as pessoas à discriminação e violência. Desse modo, o processo de estigmatização é operado por meio do poder exercido pelas leis da heterossexualidade compulsória sobre os corpos. Entretanto, durante as trajetórias de vida das travestis e mulheres transexuais, estratégias de resistência contra o estigma são produzidas com o potencial de transformação dos quadros estabelecidos.

Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: Data from the Seek, Test, Treat, and Retain Harmonization Initiative

Background

Transgender persons are highly victimized, marginalized, disproportionately experience incarceration, and have alarmingly increased rates of HIV infection compared to cis-gender persons. Few studies have examined the HIV care continuum outcomes among transgender women (TW), particularly TW who are involved with the criminal justice (CJ) system.

Methods

To improve our understanding of HIV care continuum outcomes and risk behaviors among HIV-infected TW who are involved with the CJ system, we analyzed data from the National Institute on Drug Abuse-supported Seek, Test, Treat, Retain (STTR) Data Harmonization Initiative. Baseline data were pooled and analyzed from three U.S. STTR studies to examine HIV risk and care continuum indicators among CJ-involved HIV-infected TW compared to cisgender men (CM), matched on age (within 5 years) and study at a ratio of 1:5.

Results

Eighty-eight TW and 440 CM were included in the study. Among matched participants, TW were more likely to report crack and cocaine use compared to CM (40%,16% respectively, p<0.001); both TW and CM reported high rates of condomless sex (58%, 64%, respectively); TW were more likely than CM to have more than one sexual partner (OR = 2.9, 95% CI: 1.6, 5.2; p<0.001) and have engaged in exchange sex (OR = 3.9, 95% CI: 2.3, 6.6; p<0.001). There were no significant differences between TW and CM in the percentage currently taking ART (52%, 49%, respectively), the mean percent adherence to ART (77% for both groups), and the proportion who achieved viral suppression (61%, 58%, respectively).

Conclusions

HIV-infected CJ-involved TW and CM had similar use of ART and viral suppression but TW were more likely than matched CM to engage in exchange sex, have multiple sexual partners, and use crack/cocaine. TW and CM had similarly high rates of condomless sex and use of other drugs. TW require tailored risk reduction interventions, however both CJ-involved TW and CM require focused attention to reduce HIV risk and improve HIV continuum of care outcomes.

Understanding and Reducing Sexual Prejudice in Jamaica: Theoretical and Practical Insights From a Severely Anti-Gay Society

Jamaica has earned an international reputation for severe sexual prejudice-perhaps disproportionately so compared to other severely anti-LGBT (lesbian, gay, bisexual, and transgender) societies. Until recently, however, no quantitative empirical research had investigated Jamaica's sexual prejudice, leaving the prejudice poorly understood and methods of reducing it unclear. This article reviews empirical research on Jamaican anti-LGBT prejudice from the past 15 years. It situates Jamaica within the global context, explains the current understanding of the severity and nature of the problem, evaluates solutions currently being explored, and suggests promising strategies based on available evidence. Importantly, this article also reflects on lessons learned from Jamaica that are relevant for other severely anti-LGBT societies.

Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens

Discrimination has long been tied to health inequality. Rejected by families and communities because of their gender identity and gender-role behavior, transgender individuals are often socially marginalized. This study aimed to assess discrimination in health-care settings among persons self-identifying as transgender in the U.S. in relation to their recognizability as transgender, operationalized as how often they experienced that others recognized them as transgender. Data were obtained from the National Transgender Discrimination Survey (n = 6106 participants, assigned sex at birth = 3608 males, 2480 females, respectively). Binary logistic regressions were performed to examine associations between transgender recognizability and discrimination in health-care settings. Being recognized as transgender to any extent had a significant effect on perceived discrimination in health care. Always recognized as transgender showed significant associations with discrimination in a health-care setting (OR 1.48) and the following individualized health-care settings: social service settings (rape crisis and domestic violence centers, OR 5.22) and mental health settings (mental health clinic and drug treatment program, OR 1.87). Sex work and other street economy, which are known experiential factors affected by discrimination, were also significantly associated with discrimination in health-care settings. Discrimination in health-care settings is pervasive for transgender who are recognized as transgender. Public health efforts to improve access to equitable health care for transgender individuals may benefit from consideration of demographic, experiential, and medical risk factors to more fully understand the source of the seemingly excess risk of discrimination among persons recognized by others as being transgender.

Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County

In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including "fillers"), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women.

Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care

Purpose

The purpose of this study was to examine the perceived satisfaction and barriers to care for transgender patients after they decide to undergo gender-affirming surgery (GAS).

Method

A survey consisting of 21 multiple-choice and short-answer questions was distributed to transgender organizations and online forums across Canada and the United States. The data were then analyzed using descriptive statistics.

Results

There were 32 participants, 12 who identified as female to male and 20 as male to female. The mean age was 36 years, with a range of 18 to 81 years. The mean age of their first GAS was 33 years, and the range of wait time was 6 months to 7 years. Most of the participants received information about GAS from transgender websites and transgender surgery clinics (91% and 50%, respectively). Most participants (74%) felt like they had access to appropriate care and 89% felt like their surgeons provided enough information about GAS. There were 38% of participants who would change their experience with GAS. Participants stated several barriers toward receiving GAS: financial (73%), finding a physician (65%), and access to information (63%). Surgical transition was important to the quality of life for 91% of participants and 100% were happy with their decision to undergo GAS.

Conclusions

Transgender participants demonstrated that GAS is important to their quality of life and this study showed significant barriers to GAS.

Gender Minority Stress and Depressive Symptoms in Transitioned Swiss Transpersons

Compared to the general population, transpersons are exposed to higher levels of discrimination and violence. The stigmatization of transpersons can lead to physical and psychological problems. In particular, transindividuals exhibit a higher prevalence of depression compared to the cispopulation. The gender minority stress model (GMSM) provides a comprehensive theoretical basis to interpret these biopsychosocial interactions. Using the GMSM, this study aimed to identify associations between experience of stigmatization and the mental health of transitioned transpersons using correlational analyses and multiple regression models. In total, 143 transpersons were recruited. Multivariate analyses identified three variables (i.e., unemployment, nonaffirmation of gender identity, and internalized transphobia) to explain variance of depressive symptoms. Furthermore, a mediation of the proximal factors between distal factors and depressive symptoms was found. However, the moderating effect of resilience factors was not demonstrated. The results confirmed the importance of distal and proximal minority stressors for the mental health of transpersons. At the same time, the protective influence of resilience factors seemed to be surprisingly minor. In the treatment of transpersons, practitioners should not only focus on somatic aspects, but also consider the person's previous experiences of stigmatization.

The Importance of Human Immunodeficiency Virus Research for Transgender and Gender-Nonbinary Individuals

Transgender and gender-nonbinary (trans/GNB) individuals are disproportionally affected by human immunodeficiency virus (HIV), yet they are not adequately represented in HIV research and often underserved in clinical care. By building on community strengths and addressing structural, psychological and biological challenges, we can improve the engagement of trans/GNB people in research and ultimately improve prevention, testing, and care for this population. Here, we review the current state of the science related to HIV for trans/GNB people and discuss next steps to expand research that aims to improve the lives and well-being of trans/GNB persons.

Demographic Characteristics, Components of Sexuality and Gender, and Minority Stress and Their Associations to Excessive Alcohol, Cannabis, and Illicit (Noncannabis) Drug Use Among a Large Sample of Transgender People in the United States

The current study examined demographics, sexual orientation, gender characteristics, and gender minority stress and their association to excessive alcohol, cannabis, and illicit (noncannabis) drug use among 1210 transgender adults living in the United States. The authors conducted a secondary analysis of data that included 680 transgender women (M _age = 32.63, SD _age = 12.29) and 530 transgender men (M _age = 26.14, SD _age = 7.42). A modified version of the Risk Behavioral Assessment quantified participants' alcohol, cannabis, and illicit drug use in the past 3 months. Overall, 21.5% of participants reported excessive alcohol use; no significant differences were found on the rates of excessive alcohol use between transgender women and men. Cannabis use among our sample was 24.4%; trangender men reported significantly higher rates of cannabis use compared to transgender women. Illicit drug (noncannabis) use among our sample was 11.6%; transgender men also reported significantly higher rates of illicit drug use compared to transgender women. Multivariate analyses suggested that gender dysphoria was significantly associated with: excessive alcohol use for transgender women, cannabis use among both transgender women and men, and illicit (noncannabis) drug use among transgender women. A nonheterosexual orientation was associated with increased odds of cannabis use among transgender women and men; a nonheterosexual orientation was associated with greater odds of illicit substance use among transgender men but not among transgender women. Gender minority stressors were independently associated with excessive alcohol use among transgender men and cannabis use among transgender women. The authors suggest that minority stress may only partially account for substance use among transgender people. Consequently, the authors suggest that in addition to minority stress, other biopsychosocial mechanisms should continue to be examined to identify pathways that may lead to the development of effective substance use prevention efforts and treatment programs.

Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study

INTRODUCTION

Discrimination related to gender identity may directly influence vulnerability to HIV through increased exposure to unprotected receptive anal intercourse (URAI). Little is known about the relationship between gender-based discrimination (GBD) and URAI with stable partners among transgender women.

METHODS

This mixed-methods research began with a cross-sectional survey conducted between 2014 and 2016 with transgender women in Salvador, the capital city in one of the poorest regions in Brazil. Respondent-driven sampling was used to recruit the study population. GBD was defined through Latent Class Analysis. Additionally, 19 semi-structured interviews with participants were transcribed and analyzed through thematic content analysis.

RESULTS

URAI with stable partners was commonly reported (37.3%). GDB was positively associated with URAI among stable partners (OR = 6.47; IC 95%: 1.67-25.02). The analysis of the interviews illustrated how GBD impacted transgender women in diverse ways. Experiences with GBD perpetrated by the family often initiated a trajectory of economic vulnerability that led many to engage in survival sex work. The constant experience with GBD contributed to participants feeling an immense sense of trust with their stable partners, ultimately diminished their desire to use condoms. Further, the high frequency of GBD contributed to poor mental health overall, though some participants said engagement in transgender advocacy efforts provided a vital source of resilience and support.

CONCLUSION

Our mixed-method study capitalizes upon the strengths of diverse data sets to produce a holistic understanding of GBD and URAI with stable partners. Furthermore, by confirming the association between greater GBD and URAI, we have demonstrated how GBD can impact condom negotiation in diverse relationships.

Determinants of Transgender Individuals' Well-Being, Mental Health, and Suicidality in a Rural State

This project utilized a Community-Based Participatory Research (CBPR) approach to conduct qualitative interviews with 30 transgender adults living in a rural state. Participants' identities spanned from trans women and men to non-binary and Two-Spirit. The aim of this study was to better understand the experiences, needs, and priorities of the participants as well as to examine possible determinants of mental health, well-being, and suicidality for transgender individuals in Montana. These factors were investigated at individual, interpersonal, community, and societal levels using an ecological framework. Qualitative results indicate that participants experienced discrimination at all levels. Participants noted that discrimination contributed to mental health challenges and limited access to adequate general and transgender-specific healthcare services, both of which impacted overall well-being. This is reflected most notably in the elevated rate of past suicidal ideation attempts among the sample. Participants reported that the ability to transition, as well as other protective factors, played a role in reducing suicidality and improving mental and physical health. Our findings highlight the need to address transgender mental health through implementing changes at multiple ecological levels.

Stigma-related access barriers and violence against trans women in the Colombian healthcare system

Drawing from qualitative research conducted in a participatory action research framework with 28 transgender women in Colombia, this paper presents the stigma-related barriers to healthcare experienced by trans women and their experiences of multi-level violence within the healthcare system. The authors also discuss how advocacy work was conducted as part of the research process and how trans community leaders were involved throughout the project in order to promote policy-relevance and community-based implementation of findings. The paper concludes with a discussion of how the experiences of violence and stigmatisation within the health care system is linked to broader processes of structural stigma reproduced within Colombian society.

Targeted Victimization and Suicidality Among Trans People: A Web-Based Survey

Purpose: The aim of this study was to investigate the associations between a series of empirically known risk and protective factors and suicidality among trans people in Sweden.

Methods: Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable logistic regression analyses were performed to assess associations between contributing factors and suicide ideation in the past 12 months and lifetime suicide attempts.

Results: The analysis included 796 trans individuals, between 15 and 94 years of age, who live in Sweden. A total of 37% of respondents reported that they have seriously considered suicide during the past 12 months and 32% had ever attempted a suicide. Offensive treatment during the past three months and lifetime exposure to trans-related violence were significantly associated with suicidality. Less satisfaction with contacts with friends and acquaintances and with one's own psychological wellbeing were associated with suicide ideation in the past 12 months. Lack of practical support was associated with lifetime suicide attempts.

Conclusions: Our findings show that suicidality is directly correlated with trans-related victimization. Preventing targeted victimization is, therefore, a key preventive intervention against this elevated suicidality.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients

Background

High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals.

Objective

To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21–64 years.

Methods

Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard.

Results

Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab.

Conclusion

Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.

Internalized Transphobia, Resilience, and Mental Health: Applying the Psychological Mediation Framework to Italian Transgender Individuals

Transgender and gender nonconforming (TGNC) people are a highly-stigmatized population. For this reason, they might internalize society’s normative gender attitudes and develop negative mental health outcomes. As an extension of the minority stress model, the psychological mediation framework sheds light on psychological processes through which anti-transgender discrimination might affect mental health. Within this framework, the current study aimed at assessing in 149 TGNC Italian individuals the role of internalized transphobia as a mediator between anti-transgender discrimination and mental health, considering resilience as the individual-level coping mechanism buffering this relationship. The results suggest that both indicators of internalized transphobia (i.e., shame and alienation) mediate the relationship between anti-transgender discrimination and depression, while only alienation mediates the relationship between anti-transgender discrimination and anxiety. Furthermore, the results suggest that the indirect relation between anti-transgender discrimination and anxiety through alienation is conditional on low and moderate levels of resilience. Findings have important implications for clinical practice and psycho-social interventions to reduce stigma and stress caused by interpersonal and individual stigma.

Experiences of transgender individuals when accessing health care: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective is to synthesize existing qualitative literature examining the experiences of transgender individuals when accessing health care.

HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action

PURPOSE OF REVIEW

The purpose of this review is to summarize the available evidence-based HIV prevention interventions tailored for transgender people.

RECENT FINDINGS

A limited number of evidence-based HIV prevention interventions have been tested with transgender populations. Most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Studies addressing biomedical interventions for transgender women are ongoing. Few interventions address social and structural barriers to HIV prevention, such as stigma, discrimination, and poverty. Evidence-based multi-level interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence. Future research should address not only pre-exposure prophylaxis uptake and condom use but also structural barriers that limit access to these prevention strategies.

Unraveling Health Disparities Among Sexual and Gender Minorities: A Commentary on the Persistent Impact of Stigma

LGBT (lesbian, gay, bisexual, and transgender) populations experience disparities in health outcomes, both physical and mental, compared to their heterosexual and cisgender peers. This commentary confronts the view held by some researchers that the disparate rates of mental health problems reported among LGBT populations are the consequences of pursuing a particular life trajectory, rather than resulting from the corrosive and persistent impact of stigma. Suggesting that mental health disparities among LGBT populations arise internally, de novo, when individuals express non-heterosexual and non-conforming gender identities ignores the vast body of evidence documenting the destructive impact of socially mediated stigma and systemic discrimination on health outcomes for a number of minorities, including sexual and gender minorities. Furthermore, such thinking is antithetical to widely accepted standards of health and wellbeing because it implies that LGBT persons should adopt and live out identities that contradict or deny their innermost feelings of self.

Mental Health and the Transgender Population

Although research into the physical and mental health disparities faced by transgender and gender nonconforming (TGNC) populations is becoming more popular, historically it has been limited. It is now recognized that TGNC people experience disproportionate rates of negative mental health outcomes relative to both their gender-normative, heterosexual peers, as well as their gender-normative lesbian, gay, and bisexual (LGB) peers. The theoretical basis of current transgender mental health research is rooted in the Minority Stress Model, which postulates that we live in a hetero-centric, gender-normative society that stigmatizes and discriminates against lesbian, gay, bisexual, and transgender (LGBT) people, subjecting them to chronic stress (Hendricks & Testa, 2012; Meyer, 1995). This chronic, potentially compounding stress, is responsible for the increased risk of negative mental health outcomes in LGBT populations. TGNC people, in particular, may experience more adverse outcomes than their LGB peers due to rejection and discrimination within society at large as well as within the LGB community. [Journal of Psychosocial Nursing and Mental Health Services, 54(12), 44-48.].

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BACKGROUND

While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.

METHODS

We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.

RESULTS

Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.

CONCLUSION

The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

Anticipated HIV Stigma and Delays in Regular HIV Testing Behaviors Among Sexually-Active Young Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women

Young gay, bisexual and other men who have sex with men (YGBMSM) and young transgender women are disproportionately affected by HIV/AIDS. The success of biomedical prevention strategies is predicated on regular HIV testing; however, there has been limited uptake of testing among YGBMSM and young transgender women. Anticipated HIV stigma-expecting rejection as a result of seroconversion- may serve as a significant barrier to testing. A cross-sectional sample of YGBMSM (n = 719, 95.5%) and young transgender women (n = 33, 4.4%) ages 15-24 were recruited to participate in a one-time survey. Approximately one-third of youth had not tested within the last 6 months. In a multivariable model, anticipated HIV stigma and reporting a non-gay identity were associated with an increased odds of delaying regular HIV testing. Future research and interventions are warranted to address HIV stigma, in order to increase regular HIV testing among YGBMSM and transgender women.

Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample

Purpose: To investigate whether the prevalence of eating disorders (EDs) differs across diverse gender identity groups in a transgender sample. Methods: Secondary analysis of data from Project VOICE, a cross-sectional study of stress and health among 452 transgender adults (ages 18-75 years) residing in Massachusetts. Age-adjusted logistic regression models were fit to compare the prevalence of self-reported lifetime EDs in female-to-male (FTM), male-to-female (MTF), and gender-nonconforming participants assigned male at birth (MBGNC) to gender-nonconforming participants assigned female at birth (FBGNC; referent). Results: The age-adjusted odds of self-reported ED in MTF participants were 0.14 times the odds of self-reported ED in FBGNC participants (p=0.022). In FTM participants, the age-adjusted odds of self-reported ED were 0.46 times the odds of self-reported ED in FBGNC participants, a marginally significant finding (p=0.068). No statistically significant differences in ED prevalence were found for MBGNC individuals. Conclusions: Gender nonconforming individuals assigned a female sex at birth appear to have heightened lifetime risk of EDs relative to MTF participants. Further research into specific biologic and psychosocial ED risk factors and gender-responsive intervention strategies are urgently needed. Training clinical providers and ensuring competency of treatment services beyond the gender binary will be vital to addressing this disparity.

Risking It Anyway: An Adolescent Case Study of Trauma, Sexual and Gender Identities, and Relationality

This article presents the case of a Chinese-American adolescent with a significant trauma history who was questioning her sexual and gender identities. The implications of the client's intersecting identities for case conceptualization and treatment are considered within the framework of affirmative practices for sexual and gender minority (SGM) clients. The impacts of stress and trauma on this client's experiences-and SGM clients more broadly-are also considered, particularly with respect to how this client understood and negotiated her experiences of relational trauma. This case is intended to illustrate some best practices with SGM clients within an intersectional framework which underscores the importance of multiple salient cultural identities.

Challenges and opportunities for gender-affirming healthcare for transgender women in prison

Purpose The purpose of this paper is to briefly address three interrelated areas of concerns - victimization, housing placement and healthcare provision - related to the health and welfare of transgender women in jails, prisons and other types of detention facilities. Design/methodology/approach Drawing on a growing body of research on health risks for transgender women who are detained in facilities in California and elsewhere, the authors provide recommendations for policy and practice that constitutes gender-affirming healthcare for transgender women behind bars. Findings Policymakers, correctional leaders, and prison-based clinicians have a number of opportunities to address the welfare of transgender women in jails, prisons and other types of detention facilities. Originality/value This policy brief offers concrete steps government officials can take to better meet their professional and constitutional obligations, provide higher quality care for transgender women involved in the criminal justice system, and effectuate positive changes in transgender women's health and welfare both inside and outside of carceral environments.

Factors Associated with Medical Doctors' Intentions to Discriminate Against Transgender Patients in Kuala Lumpur, Malaysia

PURPOSE

Transgender people are frequent targets of discrimination. Discrimination against transgender people in the context of healthcare can lead to poor health outcomes and facilitate the growth of health disparities. This study explores factors associated with medical doctors' intentions to discriminate against transgender people in Malaysia.

METHODS

A total of 436 physicians at two major university medical centers in Kuala Lumpur, Malaysia, completed an online survey. Sociodemographic characteristics, stigma-related constructs, and intentions to discriminate against transgender people were measured. Bivariate and multivariate linear regression were used to evaluate independent covariates of discrimination intent.

RESULTS

Medical doctors who felt more fearful of transgender people and more personal shame associated with transgender people expressed greater intention to discriminate against transgender people, whereas doctors who endorsed the belief that transgender people deserve good care reported lower discrimination intent. Stigma-related constructs accounted for 42% of the variance and 8% was accounted for by sociodemographic characteristics.

CONCLUSIONS

Constructs associated with transgender stigma play an important role in medical doctors' intentions to discriminate against transgender patients. Development of interventions to improve medical doctors' knowledge about and attitudes toward transgender people are necessary to reduce discriminatory intent in healthcare settings.

THE IMPACT OF CONSTRUCTION AND GENTRIFICATION ON AN OUTDOOR TRANS SEX WORK ENVIRONMENT: VIOLENCE, DISPLACEMENT AND POLICING

The objective of this study was to investigate how environmental and structural changes to a trans outdoor work environment impacted sex workers in Vancouver, Canada. The issue of changes to the work area arose during qualitative interviews with 33 trans sex workers. In response, ethnographic walks that incorporated photography were undertaken with trans sex workers. Changes to the work environment were found to increase vulnerabilities to client violence, displace trans sex workers, and affect policing practices. Within a criminalized context, construction and gentrification enhanced vulnerabilities to violence and harassment from police and residents.

Improving correctional healthcare providers' ability to care for transgender patients: Development and evaluation of a theory-driven cultural and clinical competence intervention

RATIONALE

Correctional healthcare providers' limited cultural and clinical competence to care for transgender patients represents a barrier to care for incarcerated transgender individuals.

OBJECTIVE

The present study aimed to adapt, deliver, and evaluate a transgender cultural and clinical competence intervention for correctional healthcare providers.

METHOD

In the summer of 2016, a theoretically-informed, group-based intervention to improve transgender cultural and clinical competence was delivered to 34 correctional healthcare providers in New England. A confidential survey assessed providers' cultural and clinical competence to care for transgender patients, self-efficacy to provide hormone therapy, subjective norms related to transgender care, and willingness to provide gender-affirming care to transgender patients before and after (immediately and 3-months) the intervention. Linear mixed effects regression models were fit to assess change in study outcomes over time. Qualitative exit interviews assessed feasibility and acceptability of the intervention.

RESULTS

Providers' willingness to provide gender-affirming care improved immediately post-intervention (β = 0.38; SE = 0.41, p < 0.001) and from baseline to 3-months post-intervention (β = 0.36; SE = 0.09; p < 0.001; omnibus test of fixed effects χ2 = 23.21; p < 0.001). On average, transgender cultural competence (χ2 = 22.49; p < 0.001), medical gender affirmation knowledge (χ2 = 11.24; p = 0.01), self-efficacy to initiate hormones for transgender women, and subjective norms related to transgender care (χ2 = 14.69; p = 0.001) all significantly increased over time. Providers found the intervention to be highly acceptable and recommended that the training be scaled-up to other correctional healthcare providers and expanded to custody staff.

CONCLUSION

The intervention increased correctional healthcare providers' cultural and clinical competence, self-efficacy, subjective norms, and willingness to provide gender-affirming care to transgender patients. Continued efforts should be made to train correctional healthcare providers in culturally and clinically competent gender-affirming care in order to improve the health of incarcerated transgender people. Future efficacy testing of this intervention is warranted.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Victimization and Human Immunodeficiency Virus-Related Risk Among Transgender Women in India: A Latent Profile Analysis

Globally, transgender women (TGW) experience multiple forms of victimization such as violence and discrimination that can place them at risk for poor sexual health. To date, research overlooks the heterogeneity in experiences of victimization among TGW. Furthermore, few studies have examined the association between victimization and sexual risk among TGW in India, despite the high burden of HIV and victimization in this community. Latent profile analysis was performed to identify patterns of victimization in a convenience sample of 299 TGW recruited from nongovernmental organizations across four states in India. Analysis of covariance was performed to examine differences in sexual risk (i.e., alcohol use before sex; inconsistent condom use with a male regular partner, a male causal partner, and a male paying partner; and having multiple sexual partners) between latent profiles. Five distinct profiles of Indian TGW were identified based on the type and severity of victimization: (1) Low victimization, (2) High verbal police victimization, (3) High verbal and physical police victimization, (4) Moderate victimization, and (5) High victimization. While controlling for age, education, income, HIV status, and marital status, results revealed that TGW in the moderate victimization and high victimization profiles had higher sexual risk than TGW in the low victimization and high verbal police victimization profiles. In addition, TGW in high verbal and physical police victimization profile had higher sexual risk than TGW in low victimization profile. These findings underscore the importance of tailoring sexual risk reduction interventions to the specific needs of TGW based on patterns of victimization.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru

Transgender women (TW) represent a vulnerable population at increased risk for HIV infection in Peru. A mixed-methods study with 48 TW and 19 healthcare professionals was conducted between January and February 2015 to explore barriers and facilitators to implementing a model of care that integrates HIV services with gender-affirmative medical care (i.e., hormone therapy) in Lima, Peru. Perceived acceptability of the integrated care model was high among TW and healthcare professionals alike. Barriers included stigma, lack of provider training or Peruvian guidelines regarding optimal TW care, and service delivery obstacles (e.g., legal documents, spatial placement of clinics, hours of operation). The hiring of TW staff was identified as a key facilitator for engagement in health care. Working in partnership with local TW and healthcare provider organizations is critical to overcoming existing barriers to successful implementation of an integrated HIV services and gender-affirmative medical care model for this key population in Peru.

Barriers in the social and healthcare assistance for transgender persons: A systematic review of qualitative studies

AIM

To explore the barriers to requesting social and healthcare assistance perceived by transgender persons and professionals involved in the assistance.

METHOD

A meta-study, qualitative systematic review, of studies published in English or Spanish, exploring the barriers, perceived by transgender persons and social and healthcare professionals, that transgender persons have when they seek social and healthcare assistance was carried out in the following databases Medline (PubMed), Scopus, Web of Science, Spanish National Research Council, CUIDEN, ProQuest, PsycINFO and CINAHL.

RESULTS

Two thousand two hundred and sixty-one articles were found in the databases searched. Seven articles met all inclusion criteria and were included in this review. The professionals highlight the uncertainty when treating transgender persons and their lack of training. Transgender persons highlight the lack of information and the sense of helplessness it creates. Perceptions of transphobia, the fragmentation of services, administrative barriers, the lack of cultural sensitivity and professional training are also considered barriers to assistance.

DISCUSSION

The findings of this study provide key information for the design of plans and programmes to improve the quality of social and health care for transgender persons.