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

Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study

BACKGROUND

Although discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating those experiences based on gender identity/expression and related factors has been limited. The aim of this study was to compare the characteristics, experiences, attitude, and expectation toward accessing healthcare service and healthcare providers of transgender women and transgender men in Thailand.

METHODS

A cross-sectional study was conducted from October 2017 to March 2018. The data were collected from transgender women and transgender men aged ≥ 18 years old who lived in Thailand using online platform via different websites and Facebook pages of local transgender group. Binary logistic regression was used to identify the factors related to the study outcomes.

RESULTS

Of 186 transgender people who responded to the questionnaire and were eligible for the study, 73.7% (95% confidence interval [CI] = 66.7-79.8) were transgender women and 26.3% (95% CI = 20.2-33.3) were transgender men. Transgender women were more likely to seek general healthcare from non-traditional healthcare services (crude odds ratio [cOR] = 4.28; 95% CI = 1.55-11.81; P = 0.005), buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18-12.83; P = 0.026), and receive healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42-18.75; P = 0.013) than transgender men. According to the results of applying a multivariable model, transgender respondents who did not know that gender-affirming healthcare services existed in Thailand were more unwilling to receive counseling from gender-affirming healthcare providers than those who did (adjusted odds ratio = 3.70; 95% CI = 1.11-12.36; P = 0.033).

CONCLUSIONS

The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician's supervision. We also found approximately 15% of transgender individuals who did not receive gender-affirming counseling services. Continuing to improve access to care for the transgender community, increasing public relations channels may encourage transgender people to access more healthcare services.

Transgender and gender diverse adults' reflections on alcohol counseling and recommendations for providers

Transgender and gender diverse (TGD) populations experience health disparities due to societal stigma that increases TGD individuals' sources of stress and decreases access to health protective resources. Research has linked experiences of stigma to risky alcohol use, yet there remains a dearth of culturally sensitive alcohol use interventions that meet the needs of TGD people. The present study was conducted to inform modifications to the content and delivery of an existing brief, telehealth, motivational intervention to decrease at-risk alcohol use among TGD adults. Individual semi-structured in-depth qualitative interviews were conducted with TGD adults who reported recent alcohol use (n = 18) to explore factors that facilitate positive interactions with health care providers and identify relevant information for alcohol use disorder treatment. Participants were recruited from an LGBTQ +-focused health center in Los Angeles, California. Two major themes and recommendations emerged: (a) A multicultural orientation of humility is important to develop productive therapeutic relationships with TGD clients when delivering motivational interviewing; (b) Due to insufficient appropriate data on alcohol use and health in TGD populations, feedback used in motivational alcohol counseling needs to be modified to better serve TGD clients. These findings show that counselors' philosophy and behavior, as well as session content, need to be considered when working with TGD populations within the context of alcohol counseling. These findings also have implications for intervention development, clinical treatment, and future research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Structural Needs, Substance Use, and Mental Health Among Transgender and Nonbinary Young Adults in the San Francisco Bay Area: Findings from the Phoenix Study

Transgender and nonbinary (trans) young adults report high rates of substance use and adverse mental health outcomes; however, few studies have examined how social, economic, and legal factors may contribute to health inequities in this population. Guided by the structural vulnerability framework, this study sought to explore structural needs and whether these needs were associated with substance use and mental health outcomes among trans young adults. Between 2019 and 2021, 215 trans young adults aged 18-29 from San Francisco Bay Area were recruited into a longitudinal study. Baseline data were used to examine bivariate and multivariable associations between structural needs and substance use and mental health outcomes. There were bivariate differences in the number of structural needs by education, income source, incarceration history, and ethnicity, and the number of unmet structural needs was associated with education and income source. After adjusting for sociodemographics, the number of structural needs was associated with daily marijuana use (AOR 1.29, 95% CI: 1.10-1.49) and suicidal ideation (AOR 1.24, 95% CI: 1.06-1.45), and the number of unmet structural needs was associated with daily marijuana use (AOR 1.30, 95% CI: 1. 10-1.55) and depressive symptoms (β 2.00, 95% CI: 1.00-3.00). Additionally, both numbers of structural needs and unmet structural needs mediated the relationship between income source (traditional employment vs. other income only) and depressive symptoms (TIE β 2.51, 95% CI: 0.99-4.04; β 1.37, 95% CI: 0.23-2.52, respectively). Findings highlight a need for multisector efforts to address structural vulnerabilities among trans young adults.

The Effect of Gender-Affirming Hormones on Gender Dysphoria, Quality of Life, and Psychological Functioning in Transgender Individuals: A Systematic Review

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many transgender (including people with binary and nonbinary identities) individuals and although controlled studies are unethical, there remains limited evidence on the impact of GAHT on gender dysphoria, quality of life (QoL), and psychological functioning. Some clinicians and policy makers use the lack of evidence to argue against providing gender-affirming care. The aim of this review is to systematically and critically assess the available literature on the influence of GAHT on improving gender- and body-related dysphoria, psychological well-being, and QoL. Using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we searched Ovid MEDLINE®, Embase®, and Ovid PsycINFO® from inception to March 6, 2019 to assess the influence of GAHT on (1) gender dysphoria, (2) body uneasiness, (3) body satisfaction, (4) psychological well-being, (5) QoL, (6) interpersonal and global functioning, and (7) self-esteem. Our search strategy found no randomized controlled trials. Ten longitudinal cohort studies, 25 cross-sectional studies, and 3 articles reporting both cross-sectional and longitudinal data were identified. While results are mixed, the majority of studies demonstrate that GAHT reduces gender dysphoria, body dissatisfaction, and uneasiness, subsequently improving psychological well-being and QoL in transgender individuals. However, all current researches are of low to moderate quality comprising longitudinal cohort studies and cross-sectional studies, making it difficult to draw clear conclusions and do not reflect external social factors unaffected by GAHT, which significantly impact on dysphoria, well-being, and QoL.

A trans agent of social change in incarceration: A psychobiographical study of Natasha Keating

OBJECTIVES

This psychobiography focuses on the advocacy work of Natasha Keating, a trans woman incarcerated in two male prisons in Australia between 2000 and 2007. Incarcerated trans women are a vulnerable group who experience high levels of victimization and discrimination. However, Natasha advocated for her rights while incarcerated and this advocacy contributed to substantial changes in the carceral system. This psychobiography uses psychological understandings of resilience as well as the Transgender Resilience Intervention Model (TRIM) to investigate the factors that enabled this advocacy.

METHOD

Data consisted of an archive of letters written by Natasha and interviews with individuals who knew her well. This psychobiography was guided by du Plessis' (2017) 12-step approach and included the identification of psychological saliencies and the construction of a Multilayered Chronological Chart.

RESULTS

Natasha's life is presented in four chapters, with each chapter including a discussion of resilience based on the TRIM.

CONCLUSIONS

The TRIM suggests that during incarceration, Natasha was able to access more group-level resilience factors than at any other time in her life. This, combined with individual resilience factors, enabled her advocacy. This finding has implications for advocacy in general as it highlights the importance of both individual- and group-level factors in enabling individuals to effectively advocate for change in their environments.

Developing the "Oppression-to-Incarceration Cycle" of Black American and First Nations Australian Trans Women: Applying the Intersectionality Research for Transgender Health Justice Framework

Trans women are disproportionately incarcerated in the United States and Australia relative to the general population. Stark racial and ethnic disparities in incarceration rates mean that Black American and First Nations Australian trans women are overrepresented in incarceration relative to White and non-Indigenous cisgender and trans people. Informed by the Intersectionality Research for Transgender Health Justice (IRTHJ) framework, the current study drew upon lived experiences of Black American and First Nations Australian trans women to develop a conceptual model demonstrating how interlocking forces of oppression inform, maintain, and exacerbate pathways to incarceration and postrelease experiences. Using a flexible, iterative, and reflexive thematic analytic approach, we analyzed qualitative data from 12 semistructured interviews with formerly incarcerated trans women who had been incarcerated in sex-segregated male facilities. Three primary domains-pathways to incarceration, experiences during incarceration, and postrelease experiences-were used to develop the "oppression-to-incarceration cycle." This study represents a novel application of the IRTHJ framework that seeks to name intersecting power relations, disrupt the status quo, and center embodied knowledge in the lived realities of formerly incarcerated Black American and First Nations Australian trans women.

Sex & relationships in trans people

Everyone has sexual rights and is entitled to enjoy sex, regardless of gender identity or expression. It is therefore encouraging to witness a recent growth in research on sexuality in transgender individuals. We provide a short overview of extant research on sex and relationships in this population and argue that current research has mostly been conducted from a medical and functional approach; there is a strong focus on negative experiences and prevention; and there is a lack of data regarding psychological and socio-relational variables. Furthermore, many studies have been conducted in a cis- and hetero-normative setting and have methodological shortcomings such as applying questionnaires that have not been validated in a transgender population. We encourage researchers to expand their focus to positive variables such as sexual pleasure and (in accordance with the biopsychosocial model) investigate subjective experiences and relationship variables when studying sexuality in transgender individuals.

"Take It Out on the Floor": Experiences of Violence Among Black LGBT House and Ball Community Youth in a Rust Belt City

Black, lesbian, gay, bisexual, and transgender (LGBT), individuals experience higher rates of violent victimization compared to their cisgender heterosexual counterparts over their life course. Among Black LGBT people, witnessing and experiencing violence have been related to poor health outcomes, including depression, risky sexual behavior, substance use, and lower engagement in healthcare services. We engaged in research to better understand the effects of violence experienced by the Black LGBT youth community. We conducted a qualitative, phenomenological study focused on the causes of violence occurring in the lives of Black LGBT youth engaged in a recreation-based community health program. The study consisted of four focus groups with Black LGBT youth (N = 24) and in-depth individual interviews with medical and social service providers who work with Black LGBT youth (N = 4). Data analysis presented three themes: (1) causes of violence, (2) the context of intracommunity violence, and (3) solutions to violence. The first theme describes the reasoning, motivation, or explanation for violence experienced by the Black LGBT youth community. The second theme, the context of intracommunity violence, describes how violence occurs specifically within Black LGBT young adult communities. The third theme, solutions to violence, describes the recommendations for addressing, reducing, and/or eliminating violence within the Black LGBT youth community. Our findings highlight the need for safe spaces, culturally-relevant services, and trusted figures for Black LGBT young adults, which can serve as mechanisms for mitigating violence.

Social Stressors and Health Among Older Transgender and Gender Diverse Veterans

Purpose: Health disparities in transgender and gender diverse (TGD) veterans compared with cisgender veterans have been documented. However, there is a paucity of literature focused on older TGD veterans. We assessed health conditions and social stressors in older TGD veterans compared with matched cisgender veterans. Methods: Using gender identity disorder diagnosis codes, we identified 1244 TGD veterans (65+ years of age) receiving care in the Veterans Health Administration (VHA) from 2006 to 2018. These TGD veterans were then matched to 3732 cisgender veterans based on age, VHA site, and date of care in VHA. Results: In adjusted models, TGD veterans compared with cisgender veterans were less likely to have alcohol use disorder (adjusted odds ratio [AOR; 95% confidence interval]: [0.70; 0.58-0.85]), drug use disorder (0.59; 0.47-0.74), tobacco use (0.75; 0.65-0.86), and anxiety (0.74; 0.62-0.90). However, compared with cisgender veterans, TGD veterans were more likely to experience depression (1.63; 1.39-1.93), Alzheimer's disease (8.95; 4.25-18.83), cancer (1.83; 1.56-2.14), violence (1.82; 1.14-2.91), social/familial problems (2.45; 1.99-3.02), lack of access to care/transportation (2.23; 1.48-3.37), and military sexual trauma (2.59; 1.93-3.46). Furthermore, compared with cisgender veterans, TGD veterans were more likely to have documentation of a higher count of social stressors: 1 or more stressors (1.64; 1.38-1.95) and 2 or more stressors (1.22; 1.01-1.49). Conclusion: Despite significant disparities in social stressors and health conditions compared with cisgender veterans, TGD veterans had a lower likelihood of substance use and anxiety. Interventions are needed to mitigate social stressors and improve health among the older TGD veteran population.

The Helping Networks of Transgender Women Living with HIV

Transgender women living with HIV face significant barriers to healthcare that may be best addressed through community-centered interventions holistically focused on their HIV-related, gender-related, and other important needs. Community health ambassador (CHA) interventions (education and training programs designed to engage communities and community leaders in health promotion) may be an effective option, though information about the natural helping networks of this vulnerable population is too limited to inform the implementation of this approach. This study uses social network analysis to describe the natural helping networks of transgender women living with HIV, their help-seeking patterns for HIV-related, gender-related, and ancillary resources, and the characteristics of potential network ambassadors. From February to August 2019, transgender women living with HIV in the US (N = 231) participated a 30-min online survey asking them to describe their natural helping networks (N = 1054). On average, participants were embedded within natural helping networks consisting of 4-5 people. They were more likely to seek help from informal network members vs. formal service providers (p < .01), and from chosen family and partners/spouses (p < .05) above other social connections. Older network members (p < .01), other transgender women (p < .05), and those with whom they regularly engaged face-to-face (p < .01) (vs. social technology) were identified as potential network ambassadors for HIV-, gender-related, and other important issues. These findings suggest an opportunity to develop CHA interventions that leverage existing help networks and potential network ambassadors to promote equitable access to HIV, gender-affirming, and other crucial resources among this medically underserved group.

Revisiting the Rainbow: Culturally Responsive Updates to a Standard Clinical Resource

PURPOSE

Cultural responsivity is essential for efficacious and affirming clinical relationships. This may be especially important with historically marginalized clients, such as transgender and gender-diverse (TGD) people seeking behaviorally based affirming communication services. We recommend modifications to standard tools for diagnostics and training that otherwise might undermine our efforts to create an inclusive and affirming environment.

METHOD

Modifications to the Rainbow Passage, a standardized paragraph utilized for eliciting speech samples in clinical settings, focused on nongendered terminology and the elimination of content with religious connotations.

RESULTS

The recommended edits to the Rainbow Passage maintain similar length, cadence, and phonetic balance while considering cultural and health care context for TGD people and other clients.

CONCLUSION

Simple linguistic changes to a standardized paragraph maintain clinical benefits and facilitate SLP efforts toward cultural responsivity, client engagement, and good clinical outcomes.

Factors Related to Treatment Attendance for Patients Seeking Gender-Affirming Voice Therapy

OBJECTIVE

The purpose of this study was to investigate factors related to treatment attendance for patients seeking gender-affirming voice therapy (GAVT).

METHOD

We completed retrospective chart reviews of 50 patients (43 transgender women, three transgender men, four nonbinary patients; aged 18-67 years, M = 34.92 years, SD = 12.32 years) referred for GAVT at a Midwest outpatient center from 2016 to 2021. Data extraction included patient demographics, therapy visit specifics (e.g., number of sessions attended, treatment completion status, and in-person vs. virtual visits) and treatment timing (in relation to the onset of the COVID-19 pandemic), and psychosocial and socioeconomic information.

RESULTS

There was no impact of treatment-timing relative to the onset of the pandemic on any attendance measure; however, patients were 1.9 times more likely to complete therapy with each virtual telehealth session attended. Individual factors of outside social support and hormone replacement therapy were positively related to the number of therapy sessions attended, whereas insurance provider and employment status were related to therapy completion.

CONCLUSIONS

Telehealth attendance during the COVID-19 pandemic was positively associated with GAVT completion. Future research should investigate psychosocial and socioeconomic factors to understand how to identify patients at risk for poor treatment adherence and facilitate access to clinical care.

Clinical and Behavioral Outcomes for Transgender Women Engaged in HIV Care: Comparisons to Cisgender Men and Women in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) Cohort

Describe health of transgender women (TW) with HIV vs. cisgender men and women (CM, CW) in a U.S. HIV care cohort. Data were from Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2005-2022. TW were identified using clinical data/identity measures. PWH (n = 1285) were included in analyses (275 TW, 547 CM, 463 CW). Cross-sectional multivariable analyses compared HIV outcomes/co-morbidities between TW/CM and TW/CW, and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated. TW had poorer adherence (> 90% adherent; aOR 0.57; 95%CI 0.38, 0.87) and were more likely to miss ≥ 3 visits in the past year than CM (aOR 1.50, 95%CI 1.06, 2.10); indicated more anxiety compared to both CM and CW (p ≤ 0.001, p = 0.02); hepatitis C infection (p = 0.03) and past-year/lifetime substance treatment (p = 0.004/p = 0.001) compared to CM; and substance use relative to CW. TW with HIV differed in HIV clinical outcomes and co-morbidities from CM and CW.

Use of substances to cope during the COVID-19 pandemic among transgender and gender diverse adults

Background: Studies have found changes in substance use during the COVID-19 pandemic in specific populations. Transgender and gender diverse (TGD) individuals have experienced greater distress compared to cisgender individuals during the pandemic; however, there is little research on substance use among TGD individuals during this sensitive time period.Objectives: The objective of this study is to examine distress from COVID-19 and coping via substance use including alcohol, cannabis, tobacco, and non-medical use of prescription drugs (NMUPD) among TGD adults.Method: An online survey assessing substance use, general psychiatric symptoms, and COVID-19 anxiety was completed by 342 TGD individuals (16.4% transfeminine, 19.6% transmasculine, 64.0% Gender Diverse) in June/July 2020. Chi-square and structural equation modeling (SEM) analyses examined the connections between distress, coping, and substance use.Results: Seventy-one percent of participants reported no changes in substance use since the start of the pandemic and 22% reported an increase in substance use. Increased substance use was associated with alcohol (p < .001), cannabis (p < .001), and combustible tobacco (p < .001) use in the prior three months. SEM showed significant direct effects between distress and substance use coping, substance use coping and recent drug use, and an indirect effect of distress on recent drug use through substance use coping (β = .31, p = .001).Conclusion: Results highlight the risk of substance use to cope with COVID-19-related stress in a large sample of a minoritized population with mental health disparities. Transmasculine and gender diverse participants were especially likely to report using substances to cope.

The Intersection of Stress, Health, and Health Care Opportunities for Appalachian Transgender and Nonbinary People: An Interpretative Phenomenological Analysis

Transgender or nonbinary (TNB) individuals in the United States South experience higher rates of physical and mental health disparities when compared to their cisgender counterparts. Societal, interpersonal, and individual stigmas contribute to these disparities by increasing the levels of stress in the TNB population, which is a primary factor in higher morbidity and mortality. However, there is a paucity of research examining the impact of these stigmas on health through the lived experiences of TNB people living in Appalachia. An interpretive phenomenological analysis (IPA) research design was used to collect and analyze semi-structured interviews with TNB individuals living in Appalachia. Transcribed interviews were analyzed repeatedly by two analysts to identify emergent themes which focused on understanding an individual's lived experiences through interpretation. Ten participants from four Appalachian states within three Appalachian sub-regions participated in this study. Three shared healthcare themes were identified: experiences of stigma related to gender, the impact of stigma on personal wellbeing and perception of health, and the need for affirming TNB healthcare services. Respondents noted that chronic stress factors such as continual and compounding experiences of stigma and discrimination, stemming from religion or lack of affirming providers, negatively impacted their health. TNB individuals living in Appalachia experience chronic societal, interpersonal, and individual stressors that negatively impact their health. By addressing the stigmas, public health leaders, policymakers, and providers can improve access to health care and the health and quality of life of Appalachian TNB people.

Food insecurity in a Brazilian transgender sample during the COVID-19 pandemic

Transgender people often live with social vulnerability, largely promoted by gender-based prejudice. Our aim in this article was to raise preliminary data on how the COVID-19 pandemic and perceived prejudice have contributed to the problem of food and food insecurity in the transgender communities in Brazil. We conducted a web-based cross-sectional study, in which 109 transgender people from all regions of Brazil participated. We used the Chi-Square test and Poisson regression modeling with robust variance to estimate the association between food insecurity and the investigated factors. In our sample, 68.8% of transgender people experienced food insecurity, of these, 20.2% experienced severe food insecurity. Our results showed that the difficulties in purchasing food in the transgender community predate the COVID-19 pandemic, yet that the restrictive measures adopted have also impacted overall access to quality food. However, the main explanations for food insecurity were income and employment. In predicting food insecurity, the experiences of prejudice must be considered, and give rise to the hypothesis that specific conditions to which transgender people are exposed explain, to some degree, their vulnerability to food insecurity.

Predictors of Empirically Derived Substance Use Patterns Among Sexual and Gender Minority Populations of a Rural Midwestern State

Purpose: The study purpose was to (1) identify latent classes of substance use behaviors among a sample of sexual and gender minority (SGM) adults living in a predominantly rural midwestern state and (2) determine the association between SGM-related discrimination and the empirically derived substance use classes. Methods: We conducted a latent class analysis on 494 responses to a state-wide survey, followed by a multinomial logistic regression to test predictors of class membership, including distal experiences of discrimination and sociodemographic variables. Results: A three-class model fit best and included (1) polysubstance use, (2) binge drinking, and (3) no/low use classes. In the adjusted model, polysubstance class membership was positively associated with cisgender male identity and negatively associated with being 60 years of age or older and college educated. Binge drinking class membership was negatively associated with bisexual/pansexual identity and non-White race/ethnicity. In contrast to hypothesized outcomes guided by the Minority Stress Model, experiences of discrimination were not associated with membership in substance-using classes. Likewise, bisexual/pansexual individuals were not more likely to be members of polysubstance use or binge drinking classes, despite published reports of greater risk of substance use. Conclusion: These contradictions warrant intersectional approaches to advance substance use research, which may provide important evidence for targeted prevention/treatment interventions, particularly among polysubstance users.

Sexual and Gender Minority Individuals' Interest in Sexual Health Services at Collective Sex Venues in New York City

Sexual and gender minority individuals who attend collective sex venues (CSVs; establishments where people can have sex in groups or the presence of others) are at elevated risk for HIV and STIs. On-site sexual health interventions have been attempted at CSVs, but attendees' interest in receiving such services is under-investigated. This paper presents results from a 2020 online cross-sectional survey completed by 342 sexual and gender minority individuals who attended CSVs in New York City. Interest in services such as on-site testing for STIs, testing vans near CSVs, and informational referrals was overall high, particularly among younger participants. Among participants who reported being HIV negative, those of younger age and those who were not using PrEP reported being more likely to take an HIV test if it would be offered at CSVs. In open-text survey responses, participants expressed interest in CSVs providing free prevention services such as HIV/STI testing, PEP, PrEP, and STI medications or vaccination, as well as in ways to improve norms surrounding condom use and consent at these venues. Some participants expressed barriers to on-site services such as privacy concerns, preexisting access to health services, an emphasis on personal responsibility, and negative reactions to the presence of service providers. However, some participants also felt that these services could be delivered in a positive, acceptable, and non-judgmental way, especially by involving CSV organizers and attendees in their implementation. Findings from this study can inform future initiatives to develop sexual health interventions at CSVs.

Understanding access to healthcare for gender diverse young people: a critical review of the literature

Gender diverse young people face well-documented physical, mental and sexual health disparities compared to the general population. Differential access to healthcare is a key driver of these inequities and literature highlights high unmet healthcare need among members of this group. Healthcare access has been described through a model that defines five dimensions of health services: approachability; acceptability; availability and accommodation; affordability; and appropriateness; and five abilities of health service consumers that interact with these dimensions: the abilities to perceive, seek, reach, pay and engage. This comprehensive literature review examined barriers to and facilitators of healthcare access among gender diverse young people using the lens provided by this model as it relates to dimensions of access at the health service level and/or the abilities of health service users. We advocate expansion of this model to incorporate demand- and supply-side barriers and facilitators of access, and important structural factors including the gender binary health system framework, intersectionality and stigma. Findings highlight the need for improvements to healthcare provider education and the participatory redesign of health services with a focus on intersectionality, individually-tailored service provision and healthcare that is responsive to the unique needs of gender diverse young people.

Establishing a university food pantry: growth, changes in shopper characteristics and recommendations

Objective: Describe trends in usage and shoppers of Eastern Michigan University's (EMU) food pantry over four academic years. Participants: Shoppers of EMU's pantry between September 2015 and April 2019. Methods: Data come from shopper questionnaires and pantry records of daily visits and food distribution. Descriptive statistics, t-tests, and chi-square analyses were used to explore shopper characteristics and pantry use over time. Results: Pantry use increased over four academic years (from 1,021 to 3,080 visits/year). An increasing proportion of shoppers use the pantry ≥ once/month (6.1% in 2015/2016; 15.1% in 2018/2019). Compared to irregular shoppers (≤7 visits/year), regular shoppers (≥8 visits) reported higher rates of housing instability and were less likely to have a university meal plan. Conclusion: Data revealed substantial growth of the campus pantry, likely reflecting greater awareness and greater need. The findings highlight financial and social challenges faced by Michigan's college students. Recommendations for pantry establishment/maintenance are indicated.

Facilitators and barriers to providing affirming care for transgender patients in primary care practices in Arkansas

PURPOSE

This study assessed factors affecting the provision of affirming-care best practices (ACBPs) for transgender individuals by primary care providers (PCPs) in a rural, southern state METHODS: We conducted a sequential explanatory mixed-methods study in 2020, including a statewide survey (phase 1) and interviews (phase 2). Surveyed PCPs (phase 1) included Medical Doctors/Doctors of Osteopathy (MDs/DOs), nurse practitioners, and 1 physician assistant. Interview participants (phase 2) included providers and staff in 6 practices throughout the state. We used an exploratory approach to data collection and performed content analysis to classify interview data into categories representing overarching themes RESULTS: Among surveyed PCPs who reported they had provided care to transgender patients (n = 35), the most common reason for providing gender-affirming medical services was "because of my ethical obligation to treat patients equally" (n = 27, 77%). The most common reason for not providing such services was because the PCPs "have not been trained/don't feel competent to provide these services" (n = 12, 34%). Interviews revealed the following themes: (1) willingness to provide "culturally competent care"; (2) continuum of accepting to affirming attitudes toward transgender individuals; (3) basic understanding of stigma and an awareness of its impact; (4) changes needed to provide "culturally competent care"; and (5) preferred clinical support strategies.

CONCLUSION

Training and education to provide ACBPs are warranted and would meet the needs of patients and providers. Facilitating telemedicine visits for transgender patients with gender-affirming care experts was a favorable implementation strategy for clinical support and is recommended to address access to affirming care.

Providing gender affirming and inclusive care to transgender men experiencing pregnancy

OBJECTIVES AND DESIGN

Information about providing professional and appropriate perinatal care to transgender men in the perinatal setting is scarce, and healthcare providers often have insufficient knowledge or skills to provide this care. In response, a quality improvement educational program for nursing staff was developed and implemented, with the goal of evaluating the impact of this intervention on nurses' knowledge, skills, and attitudes when caring for pregnant transgender men.

SETTING AND PARTICIPANTS

The training was offered to nursing staff of a 24-bed inpatient perinatal unit at a large, private academic medical center in a major East Coast city during the unit's quarterly staff meeting in March 2020.

INTERVENTION

The training covered the provision of affirming and inclusive perinatal care for transgender men. The content of the training was based on recommendations in the literature and reviewed by content experts.

MEASUREMENTS

Pre-test (N = 55) and post-test (N = 23) online self-administered surveys assessed nursing staff's knowledge of, comfort, and interest in providing gender affirming care for transgender men. Mann-Whitney U and Fischer's exact tests were used to determine significant changes in knowledge and attitudes over time.

FINDINGS

Findings suggest the training improved nursing staff's self-reported knowledge and skills in providing gender affirming care to pregnant transgender men over time, with participants demonstrating improved knowledge about communication around pronouns, gender identity, reproductive systems, and obstetric history. Awareness of resources for both professional development and to refer transgender patients also improved. However, persistent deficits in other knowledge, skills, and attitudes remained, suggesting that nurses would likely benefit from further support and training in transgender-specific health issues.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings support the utility of unit-based training in improving affirming and inclusive care in the perinatal setting. This highlights opportunities for supporting nurses' professional practice of caring for transgender patients experiencing pregnancy and may be adapted for use in other specialty units.

Factor analysis of the stigma scale-child in pediatric inflammatory bowel disease

OBJECTIVE

Illness stigma, or perceived stigma related to a chronic health condition, is pervasive among youth with inflammatory bowel disease (IBD). However, no studies exist examining the psychometric properties of illness stigma measures in this population. Using a modified version of the Child Stigma Scale originally developed for youth with epilepsy, the current study investigated the factor structure and validity of this adapted measure (i.e., Stigma Scale - Child; SS-C) in youth with IBD.

METHODS

Factor analyses were conducted to determine the most parsimonious factor structure for the adapted 8-item Stigma Scale - Child in a sample of 180 youth with IBD. Correlations were conducted to assess convergent validity, and a multiple regression was conducted to further evaluate the measure's predictive validity of child depressive symptoms.

RESULTS

The most parsimonious model for the SS-C is a one-factor solution with an error covariance between the two items assessing concealment/disclosure of IBD diagnosis.

CONCLUSIONS

The SS-C is a psychometrically sound illness stigma measure in pediatric IBD that demonstrates strong convergent validity with psychosocial adjustment factors such as thwarted belongingness, illness uncertainty, and illness intrusiveness, as well as strong predictive validity with youth depressive symptoms. The SS-C is a viable option for use as a brief screener in youth with IBD across clinical and research settings.

Exploring the intersectionality of stigma and substance use help-seeking behaviours among lesbian, gay, bisexual, transgender, queer, questioning or otherwise gender or sexuality minority (LGBTQ+) individuals in the United States: A scoping review

Problematic substance use (SU) is a significant issue among LGBTQ+ individuals, but rates of treatment/help-seeking in this population remain low. This review aimed to investigate literature about intersectional stigma of SU and LGBTQ+ identity and its impact on SU help-seeking behaviours in the U.S. Eligible studies from eight-database were included if peer-reviewed, in English, from the U.S., published between 2000 and 2022, focused on SU, stigma, SU help-seeking behaviours, among LGBTQ+ adults. Of 458 search results, 50 underwent full-text review, 12 were included in the final sample. Minority Stress Theory emerged as a relevant theoretical framework. Findings revealed that increased SU as a coping strategy was associated with minority stress. Intersectional stigma negatively impacted SU treatment experience among LGBTQ+ individuals, leading to avoidance of help-seeking or poor treatment outcomes. Patterns of SU and impact of stigma among LGBTQ+ individuals differ, wherein bisexual and transgender individuals reported significantly more treatment barriers and unique stressors. LGBTQ+ individuals reported earlier age of SU onset and were more likely to encounter opportunities for SU. This review highlights the impact of intersectional stigma on SU help-seeking behaviour among LGBTQ+ individuals in the U.S. Recommendations are provided for future clinical practice, research, and policy to better support LGBTQ+ individuals.

Feasibility of communication platforms to empower transgender cultural competence among human immunodeficiency virus screeners: A qualitative analysis

Background

Human immunodeficiency virus (HIV) screeners have limited experience of interacting with trans people. The application of communication platforms between them to empower HIV screeners' trans-related cultural competence remains unknown.

Objective

This study aims to qualitatively explore the follow-up interviews of HIV screeners regarding their opinions on the feasibility of an online platform group discussion and web page to enhance communication between them and trans people and to explore their perspectives on how these components enhanced their promotion of cultural competence.

Methods

This study was conducted between October 2020 and June 2021. Purposive and snowball sampling were applied to recruit 6 trans persons and 11 HIV screeners. Six online platform group discussions were held on weekday evenings, each group meeting for 60 min, 360 min in total within 3 months, via a video chat room of Google Meet; this was supplemented by a closed web page. The major results were presented through content analysis of the HIV screeners' follow-up interviews.

Results

The HIV screeners identified the facilitators of participating in the communication platforms, which included a reminder message, easy-to-use interface, visible-audible and readable interaction, recalled and reviewable content and group belonging; the barriers included time and space limitation, device restrictions and operation problem. Two categories of trans-related cultural competence - trans awareness and action taken - were revealed, from which five major themes emerged: provoked to ask questions, improved cognition, reflection, trans-sensitive communication and self-enhancement.

Conclusion

The results revealed that the communication platforms could facilitate the mutual and vivid discussion between HIV screeners and trans people and empower the trans-related cultural competence of HIV screeners. The highly feasible intervention design of this research can be applied to digital training courses related to gender diversity issues.

Effects of Hormones on Breast Development and Breast Cancer Risk in Transgender Women

Transgender women experience gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. Transgender people undergo different surgical procedures and receive sex steroids hormones to reduce psychological distress and to induce and maintain desired physical changes. These persons on feminizing hormones represent a unique population to study the hormonal effects on breast development, to evaluate the risk of breast cancer and perhaps to better understand the precise role played by different hormonal components. In MTF (male to female) patients, hormonal treatment usually consists of antiandrogens and estrogens. Exogenous hormones induce breast development with the formation of ducts and lobules and an increase in the deposition of fat. A search of the existing literature dedicated to hormone regimens for MTF patients, their impact on breast tissue (incidence and type of breast lesions) and breast cancer risk provided the available information for this review. The evaluation of breast cancer risk is currently complicated by the heterogeneity of administered treatments and a lack of long-term follow-up in the great majority of studies. Large studies with longer follow-up are required to better evaluate the breast cancer risk and to understand the precise mechanisms on breast development of each exogenous hormone.

Trans and Gender Diverse People's Experience Wearing Face Masks During the COVID-19 Pandemic: Findings from Data Across 4 States in the USA

Introduction

Social isolation and reduced access to public life in response to SARS-CoV-2 (COVID-19) challenges health and well-being for many. Marginalized communities, including transgender and gender diverse (TGD) people, have been disproportionally impacted. Experiences of TGD people should be centered in pandemic-related research to better inform policy.

Methods

A diverse sample of TGD people (N = 158) were recruited from Michigan, Nebraska, Oregon, and Tennessee to participate in the Trans Resilience and Health Study. Participants ranged from 19 to 70 years old (M = 33.06; SD = 12.88) with 27.2% identifying as trans men/men, 26% identifying as trans women/women, and remaining identifying with terms like genderqueer and nonbinary. Thirty percent identified as people of color. Participants completed a monthly COVID-19-related questionnaire April 2020-March 2021 including open-ended questions to learn what contributed to resilience during this time. Thematic analyses of responses enabled identification of salient themes.

Results

Analyses revealed pandemic-related changes in social experiences of marginalization and mask-wearing. Twenty-six participants mentioned face masks as contributing to resilience while also elaborating the influence of masks on experiences of misgendering. Participants identifying as trans women reported decreased misgendering while trans men and nonbinary participants reported increased misgendering.

Conclusions and Policy Implications

Mask-wearing helps reduce transmission of COVID-19. For some trans women, masks also reduce the threat of misgendering and possibly other forms of enacted stigma. However, increased risk for misgendering, as noted by trans men in our study, should be considered and increased supports should be provided.

Anti-transgender rights legislation and internet searches pertaining to depression and suicide

The purpose of this study was to examine whether anti-transgender rights legislation among state legislators is associated with increased suicide- and depression-related Internet searches. Employing a quasi-experimental non-equivalent control group design, we focused on bills that were introduced to state legislatures from July 2019 to July 2020. As our panel is constructed of 51 states/territories over a 52-week time frame, our final dataset is composed of 2,652 observations. Results showed that states' passing of anti-transgender rights bills were linked with suicide- and depression-related Internet searches. Second, introducing or debating the bills did not have an association with Internet searches. Third, the defeat of anti-transgender bills was linked with fewer depression-related searches. Finally, the LGBT context in the state affected the results: anti-transgender legislation had a particularly strong association with suicide-related Internet searches when the state had a high LGBT population density.

Normality in medicine: an empirical elucidation

BACKGROUND

Normality is both a descriptive and a normative concept. Undoubtedly, the normal often operates normatively as an exclusionary tool of cultural authority. While it has prominently found its way into the field of medicine, it remains rather unclear in what sense it is used. Thus, our study sought to elucidate people's understanding of normality in medicine and to identify concepts that are linked to it.

METHODS

Using convenient sampling, we carried out a cross-sectional survey. Since the survey was advertised through social media, we employed an online survey. We performed descriptive and inferential analyses. Predictors were chosen in a theory-driven manner.

RESULTS

In total, 323 persons from 21 countries completed the survey. Analysis revealed that the overall acceptance of normality in medicine was associated with notions of injustice, authority, discrimination, and with having a medical profession. More precisely, for the field of mental health, injustice insensitivity, genderism and transphobia, and authority were positively associated with a person's acceptance of normality; and, for the field of physical health, injustice insensitivity and having a medical profession were positively associated with a person's acceptance of normality. Finally, participants' acceptance of the use of normality in the area of mental health was lower than in the area of physical health.

CONCLUSIONS

What is considered normal has implications for clinical practice, both at an individual and at a policy-level. Acknowledging its normalistic condition, the discipline of medicine has to confront itself with its own contribution to the augmentation of social inequalities through the excessive reliance on the concept of normality. Research that centers the lived experiences of those who are being systematically marginalized because they are deemed abnormal is needed. By empirically elucidating the conceptual relationships between normality in medicine and other variables, we provide points of leverage to deprive normality of its normative power. For medicine, this is needed to first do no harm.

Discrimination against and Associated Stigma Experienced by Transgender Women with Intersectional Identities in Thailand

Although Thailand is overtly open to diversity and promotes equality, discrimination of minorities based on gender, ethnicity, and/or certain occupations is unfortunately still prevalent. Society either obstructs their inclusion or accepts them but only under certain conditions. The objective of this study is to examine the discrimination of TGWs with intersectional identities within Thai society. A total of 19 TGW participants were recruited and underwent in-depth thematic interviews about their experiences of discrimination. Rechecking of the extracted information from the interview transcripts and the subsequent encoding process were conducted using the NVivo program. The results show that the median age was 30 years old, and the majority of the individuals with intersectional identities were ethnic minority TGWs (47%). The in-depth interviews were divided into four main themes, including discrimination at an educational institution, discrimination in the workplace, discrimination in daily life, and discrimination at a healthcare facility. Our findings reflect problems associated with multiple sources of discrimination aimed at transgender women with an intersectional identity in Thailand in every aspect, including harsh speech or physical abuse; occupational, social, and legal inequality; and healthcare provision disparity. Raising awareness about gender diversity and intersectionality, as well as enforcing anti-bullying legislation and anti-discrimination laws, should be continually pursued in order to protect the rights and improve the quality of life of transgender individuals with an intersectional identity.

Caring for Transgender People in Healthcare: A Qualitative Study with Hospital Staff in Croatia

Transgender and gender-diverse people have greater health risks due to increased social stress and face a disadvantaged position in the healthcare system as a result of the stigma associated with their gender identity. Due to the lack of research in Croatia on the position of transgender people in the healthcare system, this research was intended to supplement the knowledge about the experiences of hospital staff in the Croatian healthcare system when caring for patients with transgender identities. Qualitative research was conducted using an interview method. The participants (n = 10) were healthcare managers or hospital care team members. The collected data were processed through thematic analysis. The results show that some participants had had no encounters with transgender patients and those who had described them as unproblematic or had only encountered them at a level of basic healthcare. They also described how they perceive transgender people and their life circumstances. The participants described how they envision potential encounters with this group of patients and what they consider necessary to improve the position of this group within the healthcare system. In the discussion part of the article, we assess the need for additional training regarding hospital staff, especially in terms of diversity competence, and for an increase in the visibility of transgender patients.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda

BACKGROUND

The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking.

METHODS

A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0.

RESULTS

The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV.

CONCLUSION

The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

Victimization Within and Beyond the Prison Walls: A Latent Profile Analysis of Transgender and Gender Diverse Adults

Background: Transgender and gender diverse (TGD) people are disproportionately incarcerated in the United States relative to the general population. A dearth of quantitative research has explored victimization as a risk factor for incarceration as well as the victimization experiences of formerly incarcerated TGD populations. Methods: In 2019, 574 TGD adults completed an online survey assessing sociodemographics, victimization across settings, and incarceration history. Latent class analysis was used to identify two sets of latent subgroups based on respondent's victimization experiences: 1) lifetime victimization (low; moderate; and high) and 2) classes of victimization while incarcerated (low; moderate; and high). Bivariate and multivariable logistic regression analyses examined sociodemographic, mental health, and lifetime victimization experiences associated with lifetime incarceration (Outcome 1). Among those with incarceration histories, bivariate hierarchical logistic regression analyses also explored the association between gender identity, race/ethnicity, HIV status, visual gender non-conformity, and class of victimization during incarceration (Outcome 2) . Results: Participants' mean age was 31.4 (SD = 11.2), 43.4% had a non-binary gender identity, 81.5% were White, non-Hispanic, 2.1% were living with HIV, and 13.2% had been incarcerated. In the multivariable model for Outcome 1, high levels of victimization, age, being a racial/ethnic minority, being a trans woman, living with HIV, and past-12-month polysubstance use were all associated with increased odds of lifetime incarceration (p-values < 0.05). In the bivariate hierarchical logistic regression analyses for Outcome 2, living with HIV and having a visually gender non-conforming expression were significantly associated with elevated odds of experiencing high levels of victimization while incarcerated (p-values < 0.05). Conclusion: Findings document the relationships between victimization and incarceration among TGD people as well as identify the subpopulations at greater risk for incarceration and experiencing victimization while incarcerated. Efforts are needed to prevent victimization across the life course, including while incarcerated and support TGD individuals in coping with the negative sequelae of victimization and incarceration experiences.

Geographic Distribution of Clinical Care for Transgender and Gender-Diverse Youth

OBJECTIVES

Geographic barriers limit access to clinical care in the United States for transgender and gender-diverse (TGD) youth. Some factors differentiating access to care are variability in state laws/policies, the number of available clinical care programs and mental health providers for TGD youth.

METHODS

We aggregated data from the Human Rights Campaign for pediatric clinical care programs for TGD youth, the Movement Advancement Project for state-by-state assessment of gender identity laws and policies, and Psychology Today for mental health providers for TGD youth by state. Current prevalence rates for TGD youth were applied by state with 2020 Census data. Findings were summarized as a whole and per capita by state, region, and country overall.

RESULTS

The South has the highest number of TGD youth per clinic (36 465-186 377), and the lowest average equality score in gender identity laws and policies (1.96). The Midwest has the highest number of TGD youth per mental health provider (278-1422). The Northeast has the lowest number of TGD youth per clinic (11 094-56 703), the highest average equality score in laws and policies per state (17.75), and the highest average number of TGD youth per mental health providers (87-444).

CONCLUSIONS

Findings support there are barriers to TGD youth care throughout the United States, especially the South and Midwest. Increasing medical and mental health care for TGD youth is likely to improve their health and well-being. Enacting gender identity protective laws/policies would allow for equal treatment and access to care among TGD youth.

Transgender Individuals and Digital Health

PURPOSE OF REVIEW

The goal of this review is to assess the use of digital technologies to promote the health and well-being of transgender and gender diverse (TGD) people.

RECENT FINDINGS

TGD individuals experience numerous health disparities, including low uptake of HIV prevention strategies, such as pre-exposure prophylaxis, increased HIV incidence, and suboptimal HIV-related outcomes. These health disparities are the result of widespread intersectional stigma on the basis of gender identity, gender expression, socioeconomic class, race, and ethnicity, which negatively impact access to general medical and transgender-specific health care. TGD individuals often delay or avoid essential medical services due to fear of discrimination. Clinicians frequently lack training, competence, and skills in transgender medicine, further exacerbating the health disparities faced by TGD people. Digital technologies have been used to improve research and clinical care for TGD populations through various modalities; telemedicine, telehealth and mHealth. Digital health technologies, including HIT-enabled clinical decision support, telehealth, telemedicine, and mHealth, offer innovative ways to improve health care access, improve quality of care, and reduce health disparities for TGD populations, including and beyond HIV outcomes, through enhanced care delivery, clinician education, and enhancing social support networks.

Differential Experiences of Sexual, Physical, and Emotional Intimate Partner Violence Among Transgender and Gender Diverse Adults

Various forms of intimate partner violence (IPV) are unfortunately common amongst adults in the United States, and these rates are devastatingly higher for transgender and gender diverse (TGD) individuals than for the general population. However, the TGD population is not monolithic, and is diverse regarding gender, sexual orientation, age, race/ethnicity, urbanicity, and other sociodemographic categories. This study uses data from the 2018 Michigan Trans Health Survey to explore these within group differences regarding sexual, physical, and emotional forms of IPV using chi-square tests of independence and logistic regressions. Chi square tests of independence found homelessness had significant associations across all outcome variables: "ever experienced physical violence from a partner," "ever experienced forced sex from a partner," "ever been threatened to be outed by a partner," and "ever had gender belittled by a partner." Gender identity and sexual orientation had significant associations with "ever experienced forced sex from a partner," "ever been threatened to be outed by a partner," and "ever had gender belittled by a partner." Urbanicity showed a significant association with "ever being threatened to be outed by a partner." In the logistic regressions, age indicated significantly higher likelihood of IPV physical IPV with each year of age; experiences of homelessness were significantly related to likelihood for all outcomes variables. Gender and sexual orientation were also significant across the models, with differing levels of likeliness depending on identities. Findings demonstrate a need for TGD inclusive programming, and specifically programs that target TGD persons who are older, report additional genders (meaning, multiple identities and/or identities besides transfeminine, transmasculine, or nonbinary), queer sexual orientations, and who are/have experienced homelessness. Programs are needed both in the realms of intimate partner violence prevention work and social services that support survivors of violence, such as mental health clinics, rape crisis centers, and shelters.

History of Sex Work Is Associated with Increased Risk of Adverse Mental Health and Substance Use Outcomes in Transgender Adults

Understanding factors influencing mental health and substance use in transgender and gender diverse people is critical to reducing disparities in this population. We sought to investigate whether a history of sex work was associated with increased prevalence of poor mental health, substance use, and a negative experience within drug and alcohol treatment facilities. We conducted a secondary analysis of the data of 25,204 transgender respondents of the 2015 United States Transgender Survey. We estimated multiple logistic regressions to assess the association between a history of sex work and adverse mental health and substance use outcomes. We then estimated mean prevalence of adverse outcomes by type of sex work. Finally, we performed chi-square analysis to explore differences in mistreatment at drug and alcohol treatment facilities. Respondents with a history of sex work were significantly more likely to have poorer psychological health, suicidality, and substance use after adjusting for covariates. Among those who visited drug and alcohol treatment facilities, those with a history of sex work were significantly more likely to report adverse experiences (26.34% vs. 11.63%). Our findings highlight the increased risk of adverse outcomes in transgender sex workers and emphasize the need for interventions targeting this subgroup of transgender people.

HIV prevalence among transgender women in Northeast Brazil – Findings from two Respondent Driven Sampling studies

Background

The HIV epidemic still high among key-populations in Brazil, especially among transgender women (TGW). The aim of this study was to investigate the prevalence of HIV infection among TGW and to analyze factors associated with HIV seropositivity across two cross-sectional surveys conducted in Salvador, Bahia, one of the largest urban centers of Brazil.

Methods

The studies were conducted between 2014 and 2016 and 2016-2017 and employed Respondent-Driven Sampling (RDS) sampling, comprising 127 and 161 TGW residents of Salvador, Bahia. The outcome was the positive rapid antigen testing for HIV infection. Odds ratios (OR) and 95% confidence intervals (95%CI) were obtained using binomial logistic regression.

Results

The HIV prevalence was 9.0% (95%CI: 4.2-18.2) and 24.3% (95%CI: 16.2-34.9). In the first study, factors associated with HIV prevalence were experiencing discrimination by the family (OR 8.22; 95%CI: 1.49-45.48) and by neighbors (OR 6.55; 95%CI: 1.12-38.14) as well as having syphilis (OR 6.56; 95%CI:1.11-38.65); in the subsequent study gender-based discrimination (OR 8.65; 95%CI:1.45-51.59) and having syphilis (OR 3.13; 95%CI: 1.45-51.59) were associated with testing positive for HIV.

Conclusion

We found disproportionately high HIV prevalence among TGW, which underscores the context of vulnerability for this population. The data point to the urgency for intensification and expansion of access to HIV prevention and strategies to stop discrimination in health care and services for this population.

The Role of Internalized Transphobia, Loneliness, and Social Support in the Psychological Well-Being of a Group of Italian Transgender and Gender Non-Conforming Youths

Although transgender and gender non-conforming (TGNC) youth represent a highly resilient community capable of successfully overcoming adverse life circumstances, they still face social stigma that negatively impacts their health, being at risk of developing negative feelings toward their own TGNC identity (i.e., internalized transphobia). A poorly investigated dimension in TGNC health research is perceived loneliness. Thus, within the minority stress theory, the present study aimed to investigate the mediating role of loneliness and the moderating role of social support in the relationship between internalized transphobia and psychological well-being among 79 Italian TGNC youths aged 18 to 30-years-old who participated in an online survey. The main results show that loneliness partially mediated the relationship between internalized transphobia and psychological well-being. In addition, social support emerged as a significant moderator, as the impact of internalized transphobia on psychological well-being decreased at moderate and high levels of social support, but not at low levels. The findings have significant implications for clinical practice and psychosocial interventions to reduce the impact of internalized stigma and stress on psychological health.

The nature of co-morbid psychopathology in adolescents with gender dysphoria

Gender-referred adolescents (GR) have been reported to present with considerable psychiatric symptomatology compared to their age-peers. There is, however, little research on how they compare to adolescents referred due to mental health problems (MHR). We set out to compare psychopathology in adolescents referred to our specialized gender identity unit (n = 84) and adolescents referred to a general adolescent psychiatric clinic (n = 293) in a university hospital setting in Finland. Of the GR adolescents, 40.9% had not received any psychiatric diagnosis during adolescence. Eating disorders were less common in the GR than in the MHR group, but otherwise the prevalences of disorders did not differ statistically significantly. At the symptom level, the GR adolescents displayed significantly more suicidal ideation and talk and less alcohol abuse and eating disorder symptoms than did the MHR adolescents, but otherwise their symptom profiles were comparable. Additionally, the GR adolescents had significantly fewer total externalizing symptoms than did the MHR adolescents. Adolescents seeking gender affirming treatments present with psychiatric symptoms and disorders comparable to those seen among adolescent psychiatric patients. Medical gender affirming care may not be a sufficient intervention for treating psychiatric comorbidities of adolescents with gender dysphoria.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system

PURPOSE

Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination.

METHODS

We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality.

RESULTS

A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68).

CONCLUSION

The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

Mental health and substance use risks and resiliencies in a U.S. sample of transgender and gender diverse adults

PURPOSE

Victimization contributes to mental and behavioral health inequities among transgender and gender diverse (TGD) people, but few studies have simultaneously examined health-promoting resiliencies. We sought to identify classes of risk and resilience among TGD adults, assess characteristics associated with these classes, and examine their relationship with mental health and substance use outcomes.

METHODS

Cross-sectional data were from the 2015 US Transgender Survey, a non-probability study including 26,957 TGD adults. Using latent class analysis, we classified patterns of vulnerability and resilience based on risk (past-year denial of equal treatment, verbal harassment, physical attack, bathroom-related discrimination; lifetime sexual assault, intimate partner violence) and protective (activism; family, work, classmate support) factors. Regression models were fit to (1) determine the association between sociodemographic and gender affirmation characteristics and latent classes; (2) model associations between latent classes and mental health (current serious psychological distress, past-year and lifetime suicidal thoughts and attempts, and lifetime gender identity/transition-related counseling) and substance use (current binge alcohol use, smoking, illicit drug use; past-year drug/alcohol treatment) outcomes.

RESULTS

Three latent classes were identified: high risks, with activism involvement ("risk-activism," 35%); low risks, with not being out about one's TGD identity ("not-out," 25%); and low risks, with high family support ("family-support," 40%). Gender affirmation and sociodemographic characteristics, such as race/ethnicity and sexual orientation, were associated with latent classes. Risk-activism class membership was associated with higher odds of negative mental health and substance use outcomes, while the family-support class had lower odds of these outcomes.

CONCLUSIONS

Interventions leveraging family support, and policy protections from discrimination and victimization, may promote TGD mental and behavioral health.

Transgender and Gender Diverse (TGD) Asian Americans in the United States: Experiences of Violence, Discrimination, and Family Support

Transgender and gender diverse (TGD) Asian Americans in the U.S. have multiple stigmatized identities, yet their experiences of violence and discrimination are not well understood. We utilized the 2015 United States Trans Survey, the largest survey to date with U.S. TGD people, to study the experiences of TGD Asian Americans. Our study included 699 TGD Asian Americans who experienced violence and discrimination in the form of unequal treatment, verbal harassment, and physical attack. We assessed how experiences differed by sociodemographic characteristics, including birthplace, income, age, education, disability, gender identity, and region. We also explored how family support was associated with experiences of violence in the sample. Bivariate analyses and multivariable regressions were used to understand how sociodemographic variables and family support are linked to experiences of violence and discrimination. Results indicated that income, age, disability, gender identity, and family support are significantly associated with violence and discrimination. As TGD Asian Americans currently experience high levels of violence and discrimination due to transphobia and a rapidly rising anti-Asian bias stemming from the COVID-19 pandemic, efforts to better understand factors that may increase vulnerability and identify how family support can mitigate those experiences are imperative.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis

BACKGROUND

Research indicates that tailored programming for sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, queer) people, compared to non-tailored programming, is effective for reducing the disproportionate health burden SGM people experience relative to the general population. However, the availability of SGM-tailored programming is often over-reported and inconsistent across behavioral health (i.e., substance use and mental health) facilities in the United States (U.S.).

METHODS

Using panel analysis, the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Mental Health Services Survey (N-MHSS), this study examines structural stigma and government funding as two structural determinants affecting the availability of SGM-tailored programming in the U.S.

RESULTS

Results indicated that from 2010 to 2020, reductions in structural stigma (i.e., increases in state-level supportive SGM policies) were positively associated with increases in the proportion of substance use treatment facilities offering SGM-tailored programming. This effect was significant after controlling for over-reporting of SGM-tailored programming and time- and state-specific heterogeneity. On average, the effect of reduced structural stigma resulted in approximately two new SGM-tailored programs in the short term and about 31 new SGM-tailored programs in the long term across U.S. substance use treatment facilities. Structural stigma did not predict the availability of SGM-tailored programming in mental health treatment facilities. Government funding was not significant in either data set. However, without correcting for over-reporting, government funding became a significant predictor of the availability of SGM-tailored programming at substance use treatment facilities.

CONCLUSIONS

Because SGM-tailored programming facilitates access to healthcare and the current study found longitudinal associations between structural stigma and the availability of SGM-tailored programming in substance use treatment facilities, our findings support claims that reducing structural stigma increases access to behavioral health treatment specifically and healthcare generally among SGM people. This study's findings also indicate the importance of correcting for over-reporting of SGM-tailored programming, raising concerns about how respondents perceive the N-SSATS and N-MHSS questions about SGM-tailored programming. Implications for future research using the N-SSATS and N-MHSS data and for public health policy are discussed.

HIV prevalence among transmasculine individuals at a New York City Community Health Centre: a cross-sectional study

INTRODUCTION

Multiple studies have demonstrated elevated incidence and prevalence of HIV among transgender women; however, few studies have been conducted among transmasculine individuals. HIV prevalence among transgender men in the United States is estimated to be 0-4%; however, there have not been any US studies examining HIV prevalence that stratify by the gender of sexual partners. The aim of this research was to examine HIV prevalence and its association with socio-demographic and other factors, including the gender of sexual partners and receipt of gender-affirming care (hormones/surgery), among transmasculine individuals at the Callen-Lorde Community Health Center in New York City.

METHODS

The Transgender Data Project was an Institutional Review Board-approved retrospective chart review of all transgender and gender diverse clients at the clinic, ages 18+, between 1 January 2009 and 12 December 2010. Charts were reviewed manually. Data included birth sex, gender, race/ethnicity, education, employment, housing, insurance status, gender of sexual partners, HIV screening and status, and receipt of gender-affirming care. Bivariate and multivariable logistic regression models were used to assess the association between HIV status and other variables.

RESULTS AND DISCUSSION

Five hundred and seventy-seven transmasculine individuals, mean age 32.1 years (18.3-70.5), were included in this analysis. A small majority were White (55% White, 13.9% Black and 11.7% Hispanic). The majority, 78.9%, had received hormones (testosterone) and 41.6% had received at least one gender-affirming surgery. The HIV screening rate was 43.4%. HIV prevalence was 2.8%, (95% CI: 1.13%, 5.68%) among those screened, notably higher than the US population prevalence. HIV prevalence was highest among transmasculine individuals who had sex exclusively with cisgender men (11.1%). In the multivariable model (age, education and gender of sexual partners), the adjusted odds ratio of HIV for those who had sex exclusively with cisgender male partners compared to no cisgender male partners was 10.58 (95% CI: 1.33, 84.17).

CONCLUSIONS

Although HIV prevalence has been estimated to be low among transgender men, the analysis found heterogeneous results when stratified by gender of sexual partners. The results underscore the need to understand sexual risk among transmasculine individuals and to disaggregate HIV data for those having sex with cisgender men, thus also allowing for better inclusion in HIV prevention efforts.

HIV Risk Behaviors and Psychological Well-Being Among Men Who Have Sex With Men (MSM) in Kuala Lumpur, Malaysia

HIV risk behaviors and psychological well-being among men who have sex with men (MSM) in Kuala Lumpur, Malaysia (n = 140), were quantitatively described in relation to demographic and psychosocial factors. Most participants were tested for HIV and 41.4% reported living with HIV. Malay participants had significantly higher levels of depression (p < .05), homophobia (p < .01), and needs for social support (p < .01) than Chinese. More Chinese participants reported suicidal thoughts than Malaysians (p < .05). A multivariate analysis revealed that participants with gay/MSM-identified or had lower levels of self-esteem showed significantly higher levels of depression. Future intervention projects should address depression and mental health issues among MSM and strengthen self-esteem and social support through culturally competent support and individual counseling programs (e.g., addressing MSM's conflicts with religious beliefs and norms). Structural changes must be made incrementally to reduce homophobia against MSM in Malaysia while advocating human rights.