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

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Blood count reference intervals for the Brazilian adult population: National Health Survey

OBJECTIVE

To estimate the reference intervals (RIs) of complete blood count parameters in the Brazilian adult population.

METHODS

Cross-sectional study, with data from the National Health Survey (Pesquisa Nacional de Saúde - PNS), between 2014-2015. The final sample consisted of 2,803 adults. To establish the RIs, exclusion criteria were applied, outliers were removed and partitions were made by gender, age, and race/skin color. The non-parametric method was adopted. Differences were assessed using the Mann Whitney and Kruskal Wallis tests (p≤0.05).

RESULTS

There were statistically significant differences for the following hematological parameters based on gender, red blood cells, hemoglobin, hematocrit, MCH, MCHC, eosinophils and absolute monocytes, neutrophils and platelets (p≤0.05). When analyzed by age, the RIs were statistically different in females for hematocrit, MCV, white blood cells and RDW and in males for red blood cells, white blood cells, eosinophils, mean platelet volume, MCV, RDW, and MCH (p≤0.05). For race/color, there were differences in the RIs for parameters of hemoglobin, MCH, MCHC, white blood cells and mean platelet volume, neutrophils and absolute eosinophils (p≤0.05).

CONCLUSION

The differences found in the RIs of some in blood count parameters in Brazilian adults reaffirm the importance of having their own laboratory reference standards. The results can support a more accurate interpretation of tests, adequate identification and disease prevention in Brazil.

Exploring gender dysphoria and related outcomes in a prospective cohort study: protocol for the Swedish Gender Dysphoria Study (SKDS)

INTRODUCTION

There has been a drastic increase in the reported number of people seeking help for gender dysphoria in many countries over the last two decades. Yet, our knowledge of gender dysphoria and related outcomes is restricted due to the lack of high-quality studies employing comprehensive approaches. This longitudinal study aims to enhance our knowledge of gender dysphoria; different aspects will be scrutinised, focusing primarily on the psychosocial and mental health outcomes, prognostic markers and, secondarily, on the underlying mechanisms for its origin.

METHODS AND ANALYSIS

The Swedish Gender Dysphoria Study is an ongoing multicentre longitudinal cohort study with 501 registered participants with gender dysphoria who are 15 years old or older. Participants at different phases of their clinical evaluation process can enter the study, and the expected follow-up duration is three years. The study also includes a comparison group of 458 age- and county-matched individuals without gender dysphoria. Data on the core outcomes of the study, which are gender incongruence and experienced gender dysphoria, body satisfaction and satisfaction with gender-affirming treatments, as well as other relevant outcomes, including mental health, social functioning and life satisfaction, are collected via web surveys. Two different research visits, before and after starting on gender-affirming hormonal treatment (if applicable), are planned to collect respective biological and cognitive measures. Data analysis will be performed using appropriate biostatistical methods. A power analysis showed that the current sample size is big enough to analyse continuous and categorical outcomes, and participant recruitment will continue until December 2022.

ETHICS AND DISSEMINATION

The ethical permission for this study was obtained from the Local Ethical Review Board in Uppsala, Sweden. Results of the study will be presented at national and international conferences and published in peer-reviewed journals. Dissemination will also be implemented through the Swedish Gender Dysphoria Study network in Sweden.

Transgender Health Care Primer for Clinical Audiologists

PURPOSE

Transgender people have been increasingly visible in society. Recent research has indicated that millions of Americans, 0.7% of the total population, identify as transgender. Although transgender people experience all the same auditory and vestibular disorders as people who are not transgender, there is a dearth of information about transgender issues in audiology graduate education and continuing education. The author discusses their positionality as a transgender audiologist and provides guidance on working with transgender patients from their experience and from the published literature.

CONCLUSION

This tutorial provides an overview of transgender identity for clinical audiologists and summarizes the social, legal, and medical landscape of transgender identity as it relates to audiology.

Have You Heard the News? The Effects of Exposure to News About Recent Transgender Legislation on Transgender Youth and Young Adults

Introduction

Over the last 3 years, there has been a proliferation of legislation aimed at restricting the rights of transgender Americans, including their access to gender-affirming health care. While the health implications of not having access to gender-affirming care are well documented, there may be additional indirect harms associated with proposing this type of legislation, such as those associated with being exposed to negative messages about transgender people or having to contend with friends and family who support the legislation.

Methods

This study was conducted between September and November 2021 and used a mixed-methods design to examine the implications of consuming news related to the recently proposed legislation as well as perceiving that people in one's social network support such legislation on the health and well-being of transgender youth and young adults (n = 113).

Results

Results showed that news consumption was associated with increased rumination and physical health symptoms and that perceived support for the legislation was associated with greater rumination, depressive symptoms, physical health symptoms, and fear of disclosing one's identity. Themes from the open-ended questions further underscored that the current legislation has impacted transgender youth and young adults' access to general health care; increased experiences of discrimination and other maltreatment; and resulted in some respondents engaging in unhealthy coping responses.

Conclusions and Policy Implications

Policy makers should consider these adverse consequences when responding to current, and crafting future, legislation directed at transgender Americans.

Creating change with families: Reflections and recommendations for the care of gender diverse and LGBTQIA+ individuals and their families throughout pregnancy and birth

OBJECTIVE

To derive a deeper understanding of transgender and non-binary people's experience of pregnancy and birth, and ways to modify practice to provide inclusive care.

DESIGN

Case study reports describe the experiences of two transgender and non-binary people who received pregnancy and birth care through a Midwifery Group Practice program.

SETTING

A tertiary hospital in metropolitan South Australia with approximately 3800 births per annum.

METHODS

Qualitative methodology, utilising open-ended, semi-structured, face-to-face interviews were undertaken postnatally. Interviews were audio recorded and transcribed verbatim to analyse and identify themes.

FINDINGS

Both clients feared being misgendered within pregnancy care services. They appreciated the constancy of the Midwifery Group Practice midwife, which meant they did not have to repeat their history to multiple health care providers. They appreciated their pronouns being documented on case notes and welcomed staff attempts to use their preferred terms. Both felt the pregnancy care environment was focussed on cisgender females and found this alienating. They appreciated the midwife's suggestion that the cot card for their baby did not have to be pink or blue. They both suggested staff use more gender-neutral language, and resources, when providing pregnancy care.

KEY CONCLUSION

Staff attempted to support these parents, and this was appreciated by them, but the continuity provided by the Midwifery Group Practice model was highly valued by both, regardless of risk status. It was identified that further education for staff was required to facilitate provision of more inclusive care.

IMPLICATIONS FOR PRACTICE

The case studies identified a need for greater awareness and education for staff regarding care provision for transgender and non-binary people. Simple adjustments had a big impact. Further research is needed to identify how best to meet the needs of gender-diverse people and address the educational needs of staff.

Associations between HIV stigma, gender, and depression among people living with HIV in Hyderabad, India

The goal of this study was to explore the association between HIV stigma and depression and whether gender moderated this relationship. The theoretical framework for the study combined an adapted version of Goffman's conceptualization of stigma with gender role theory. We surveyed 150 individuals living with HIV in Hyderabad, India (51 cisgender women, 49 cisgender men, and 50 third gender people) on their experiences with HIV stigma. While third gender people had statistically higher scores for HIV stigma over their cisgender counterparts, the association between each of three different forms of stigma (internalized stigma, perceived stigma, and experienced stigma) on depression was negatively moderated by third gender status. This demonstrates that third gender research participants who experienced certain forms of HIV stigma were less likely to be depressed than cisgender participants. These findings indicate resilience amongst third gender people living with HIV and can be used to better tailor social policies and gender-affirming HIV care programs in south India.

Daily experiences of minority stress and mental health in transgender and gender-diverse individuals

Transgender and gender-diverse people experience various minority stressors although minimal research has examined prospective effects on daily affect or mental health. We explored rates of marginalization for transgender and gender-diverse participants in a daily diary study and the concurrent and prospective associations with daily affect and weekly measures of depression and anxiety symptoms, as well as the mediating effects of internalized stigma, rumination, and isolation. There were 167 participants (82.2% white; M age = 25) retained in the daily surveys. Participants completed surveys for 56 days reflecting exposure to marginalization, gender nonaffirmation, internalized stigma, rumination, isolation, affect (negative, anxious, and positive affect), and mental health (anxiety and depression symptoms). Participants experienced marginalization on 25.1% of the days. Within-person analyses revealed concurrent associations between marginalization and gender nonaffirmation with increased negative and anxious affect and increased anxiety and depression symptoms, as well as associations for gender nonaffirmation and decreased positive affect. At the within-person level, there were prospective associations between marginalization and gender nonaffirmation with increased negative affect on the next day, as well as increased anxiety and depression symptoms the next week. Concurrent analyses revealed significant indirect effects with marginalization and gender nonaffirmation associated with all three affect variables and mental health via increases in internalized stigma, rumination, and isolation. However, only gender nonaffirmation was related to isolation and affect or mental health in the prospective analyses. Clinical considerations include strategies to address the immediate effects of minority stress as well as the long-term interpersonal effects. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk

BACKGROUND

Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination.

SETTING

This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019.

METHODS

We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing).

RESULTS

Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services.

CONCLUSIONS

Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.

Stronger together: community participation, structural stigma, and depression among sexual and gender minority adults in 28 European countries

PURPOSE

Although discriminatory laws, policies, and public attitudes (i.e., structural stigma) are linked to adverse mental health outcomes among sexual and gender minority (SGM) populations, little attention has been paid to protective factors, such as community participation, about which inconsistencies exist whether it ameliorates or exacerbates mental health burdens. Thus, we examined the mediator roles of identity disclosure and victimization and the moderator role of structural stigma in the association of community participation with depression.

METHODS

Data from the EU-LGBTI-II survey assessing community participation, identity disclosure, victimization, and depression among sexual minority men (n = 62,939), women (n = 38,976), and gender minority adults (n = 15,845) in 28 European countries were used. Structural stigma was measured as discriminatory legislation, policies, and societal attitudes using publicly available data.

RESULTS

Findings showed that community participation predicted lower and higher levels of depression through identity disclosure and victimization, respectively. For sexual minority men and women, structural stigma moderated the indirect effect through identity disclosure, with a larger effect in higher structural stigma countries. Only for sexual minority men, the indirect effect through victimization was also moderated, with a larger effect in high-stigma countries. For gender minorities, no moderation effect was found.

CONCLUSIONS

Community participation is differentially linked to depression through identity disclosure and victimization, and as a function of structural stigma. It can be a double-edged sword, especially for sexual minority men in high-stigma countries, who are expected to pay the price while enjoying its benefits, highlighting the targets and considerations for interventions.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults

Purpose

Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating.

Methods

A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006).

Results

The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA.

Conclusion

By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

Partial Regret After Gender Affirmation Surgery of a 35-Year-Old Taiwanese Transgender Woman

Gender-affirming surgery (GAS) is often sought after to alleviate the distress of those who suffer from gender dysphoria (GD). While many studies have shown that a significant percentage of people benefit from this procedure, a number of individuals later regret their decision of undergoing surgery. Studies have illustrated what regret depicts, categorizing regret based on intensity, persistency, and sources, in the hopes to prevent an unwanted irreversible intervention. Here, an in-depth interview with a 35-year-old transwoman from Taiwan who underwent feminizing GAS at the age of 31 illustrates her unique cultural upbringing and the course of her regret. Her experience best matches the characteristics of true regret and major regret based on the classifications of Pfäfflin and Wiepjes, respectively, indicating that she expected GAS to be the solution to her personal acceptance issue, but, in retrospect, regretted the diagnosis and treatment as her problems were not solved and worsened to the extent of secondary dysphoria. This case report hopes to shed light on the complexity of GD and regret after GAS, while encouraging the pre-surgical evaluation of psychological comorbidities and post-surgical psychotherapy, and ensuring that patients are informed and give full consent. In addition, more elaborate, long-term, large-scale qualitative research, especially within more conservative cultural settings, is needed.

Makeshift medicine is a response to US health system failures

The ‘makeshift medicine’ framework describes how individuals address healthcare needs when they are unable to access the US healthcare system. The framework is applied to gender-affirming care, the health of people who inject drugs and abortion access. Recommendations for future research, advocacy and policy are made.

Blurred border or safe harbor? Emotional well-being among sexual and gender minority adults working from home during COVID-19

During the COVID-19 pandemic, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults have experienced pronounced declines in well-being. However, less is known about how changes to daily routines and settings, such as the shift to remote work within many occupations, may be playing a role in well-being outcomes. Drawing on a unique time diary data source (N = 3515 respondents and 7650 episodes) collected between April 2020-July 2021 through online crowdsourcing platforms, we conducted random effects analyses to examine how working from home has been associated with experienced well-being among LGBTQ and cisgender heterosexual workers in the United States during the pandemic. Findings indicate LGBTQ adults felt significantly less stressed and tired while doing paid work at home than while working at a workplace. In addition, working at a workplace, rather than working from home, appeared to be more detrimental to LGBTQ adults' well-being compared to their non-LGBTQ counterparts. Adjusting for work characteristics explained some of the difference, whereas adjusting for family characteristics had little impact on the results. It is possible that for LGBTQ employees, working from home mitigates some of the minority stressors experienced during paid work.

Barriers to oral health care for transgender and gender nonbinary populations

BACKGROUND

Despite health disparities and barriers to medical care being well documented in the literature, transgender and gender nonbinary (TGNB) people's experiences and expectations with regard to oral health care remain understudied. The authors examined gender identity-related factors influencing experiences in the dental setting, aspects of subjective oral health, and avoidance of oral health care.

METHODS

One-hundred eighteen TGNB people aged 13 through 70 years completed a 32-item questionnaire designed for this study. Data analysis relied on descriptive methods and bivariate comparisons using a conventional P < .05 statistical significance criterion. Qualitative description analysis was used to identify emerging themes from responses to an open-ended question.

RESULTS

One-third of participants reported misgendering (that is, had been addressed by their incorrect name and pronouns in the dental setting). Although refusal of oral health care was rare in this sample of TGNB participants, more than one-half felt that their usual source of oral health care was not equipped to provide gender-appropriate care. Participants' avoidance due to gender identity was significantly associated with measures of self-reported suboptimal oral health. Common themes related to participants' oral health care experiences included gender insensitivity, awkward interactions, avoidance of care, and lack of gender-affirming providers.

CONCLUSIONS

Discrepancies between TGNB patients' expectations and actual experiences suggest that their needs are often unmet in the dental setting, possibly contributing to gender identity-associated dental avoidance and oral health disparities.

PRACTICAL IMPLICATIONS

Although these results need to be verified in larger and more diverse samples, they provide actionable information for improvement to this population's oral health and management.

Implementation and effectiveness of transgender stigma reduction interventions in sub-Saharan Africa: a scoping review

Background

The transgender or trans population is one of the most marginalized social groups globally, frequently experiencing ill-treatment and discrimination. This is disproportionately higher in sub-Saharan Africa where trans people experience stigma even in healthcare settings. There is limited evidence concerning the implementation and outcomes of interventions to mitigate this stigma. Therefore, this scoping review aimed to describe interventions and determine their effectiveness in reducing transgender stigma in sub-Saharan Africa.

Methods

Searches (completed November 01, 2021, and re-run May 2022) were conducted in MEDLINE (via PubMed), Cochrane Library including the Cochrane Central Register of Controlled Trials, EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of science, clinicaltrials.gov, and online grey literature sources to identify publications that described interventions to reduce transgender stigma in sub-Saharan Africa.

Results

From 877 literature search results, 23 full-text articles were assessed. Data were extracted from the four (4) eligible papers. Only one study explicitly mentioned transgender people. Second, while two studies incorporated conceptual frameworks, they did not show how the frameworks guided the study. The four studies implemented unique interventions at various socio-ecological levels to address individual and interpersonal and structural stigma. Each study utilized a different methodological approach, and the interventions were all evaluated qualitatively.

Conclusions

There is a paucity of transgender stigma reduction interventions implemented in Sub-Saharan Africa with limited evidence of interventions delivered to mitigate stigma at interpersonal and structural levels. Future anti-transgender stigma research should consider reporting details about the core components and descriptions of the interventions. Additionally, the use of validated measures of stigma and the evaluation of interventions for implementation outcomes would be helpful.

Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.

Medical attitudes towards transgender patients

Background/Aims

Those identifying as transgender make up a significant and growing number of individuals. They face discrimination in healthcare and have been known to have adverse physical and mental health outcomes because of stigma. A study was carried out to ascertain how doctors perceive and interact with their transgender patients.

Methods

The attitudes of doctors, working in mental and physical healthcare settings in a borough in south-east England, towards transgender patients were evaluated by administering a standardised questionnaire.

Results

The response rate was 22%. Most doctors who responded had encountered a transgender patient, but consultants were more likely to identify and interact with them comfortably, used their preferred pronouns, and knew about policies relating to their care than trainee doctors.

Conclusions

These findings add to the growing data regarding the perceptions about transgender patients in healthcare settings.

Disparities in health condition diagnoses among aging transgender and cisgender medicare beneficiaries, 2008-2017

Introduction

The objective of this research is to provide national estimates of the prevalence of health condition diagnoses among age-entitled transgender and cisgender Medicare beneficiaries. Quantification of the health burden across sex assigned at birth and gender can inform prevention, research, and allocation of funding for modifiable risk factors.

Methods

Using 2009-2017 Medicare fee-for-service data, we implemented an algorithm that leverages diagnosis, procedure, and pharmacy claims to identify age-entitled transgender Medicare beneficiaries and stratify the sample by inferred gender: trans feminine and nonbinary (TFN), trans masculine and nonbinary (TMN), and unclassified. We selected a 5% random sample of cisgender individuals for comparison. We descriptively analyzed (means and frequencies) demographic characteristics (age, race/ethnicity, US census region, months of enrollment) and used chi-square and t-tests to determine between- (transgender vs. cisgender) and within-group gender differences (e.g., TMN, TFN, unclassified) difference in demographics (p<0.05). We then used logistic regression to estimate and examine within- and between-group gender differences in the predicted probability of 25 health conditions, controlling for age, race/ethnicity, enrollment length, and census region.

Results

The analytic sample included 9,975 transgender (TFN n=4,198; TMN n=2,762; unclassified n=3,015) and 2,961,636 cisgender (male n=1,294,690, female n=1,666,946) beneficiaries. The majority of the transgender and cisgender samples were between the ages of 65 and 69 and White, non-Hispanic. The largest proportion of transgender and cisgender beneficiaries were from the South. On average, transgender individuals had more months of enrollment than cisgender individuals. In adjusted models, aging TFN or TMN Medicare beneficiaries had the highest probability of each of the 25 health diagnoses studied relative to cisgender males or females. TFN beneficiaries had the highest burden of health diagnoses relative to all other groups.

Discussion

These findings document disparities in key health condition diagnoses among transgender Medicare beneficiaries relative to cisgender individuals. Future application of these methods will enable the study of rare and anatomy-specific conditions among hard-to-reach aging transgender populations and inform interventions and policies to address documented disparities.

HIV Risk Perception and Pre-Exposure Prophylaxis (PrEP) Awareness Among Transgender Women from Mexico

This study aimed to identify factors associated with HIV risk perception among Mexican transgender women (TGW). This cross-sectional survey was conducted online and at a public HIV clinic in Mexico City. Participants were ≥ 18 years old, self-identified as TGW, and reported not living with HIV. They answered questions on sexual behavior, HIV risk perception, and pre-exposure prophylaxis (PrEP) awareness. We performed a multivariate logistic regression to accomplish the study's objective. One hundred ninety-one TGW completed the survey. High HIV risk perception was associated with > 5 sexual partners, condomless receptive anal sex, sex with a male partner(s) of unknown HIV status, and PrEP awareness. Although most TGW reported low HIV risk perception, over half had risk sexual behavior, reflecting inaccurate risk assessment. Future interventions to improve accurate risk perception among TGW should promote HIV transmission and prevention knowledge and increase PrEP awareness and uptake.

Mapping transgender policies in the US 2017-2021: The role of geography and implications for health equity

Transgender individuals globally face varying policy contexts that can influence their health. In the United States (US), a patchwork of exclusionary and inclusive policies exists, creating potentially different social and political contexts that shape transgender health depending on the state. In this article, we consider how recent legislation introduced in US states focused on transgender people may be a political determinant of health and affect health equity goals. To advance this aim, we employed the perspective of legal epidemiology to systematically search a US legal database (Westlaw) for policies focused on transgender individuals proposed between January of 2017 and September of 2021.698 policies were analyzed as affirming or exclusionary of transgender identities and categorized by content. We calculated a ratio of affirming versus exclusionary bills to create "exclusionary density" and "affirming density" measures. Those measures were used to calculate an inclusivity score and corresponding maps of inclusivity and exclusionary contexts by US state. Exclusionary and affirming density measures showed deeply polarized policy responses to transgender individuals depending on US state. Further, we observed differences in magnitude regarding the laws being proposed. Exclusionary laws largely focused on criminalization while inclusionary laws focused on representation in government agencies. These findings highlight that transgender individuals in the US can experience vastly different political contexts depending on where they live.

"Through the Things That Have Happened to Me, They've Made Me Stronger": Individual and Interpersonal Sources of Violence and Resilience Among a Diverse Sample of Transgender Women in Los Angeles

Within the United States, transgender women face a disproportionate burden of violence, experiencing increased rates of multiple forms of violence compared with cisgender women and other sexual/gender minority groups. Among transgender women, further racial/ethnic disparities in experiences of violence exist. Resilience has been shown to be protective against the adverse impacts of violence on mental and physical health outcomes, yet little is known about unique sources of resilience, coping, and strength among transgender women. Sixteen in-depth interviews were conducted with a racially diverse sample of transgender women between May and July, 2020 in Los Angeles. Participants were between the ages of 23 and 67 years. Four participants identified as African American/Black, four as Latina, four as White, two as Asian, and two as Native American. Participants were recruited from a local social service organization. Interview questions assessed social network characteristics, experiences of violence, coping mechanisms, and sources of resilience in response to violence. Deductive and inductive coding schemes were used to identify common themes, and data analysis focused upon experiences of violence and sources of resilience/coping. Violence was common among members of the sample, with every participant reporting a history of multiple forms of violence. Violence perpetration came from many sources, including cisgender male strangers, family members, intimate partners, and other transgender women. Women also reported multiple sources of strength and coping, including engaging in self-care and leisure activities, behavioral adaptations, mentorship/support from other transgender women, and striving to "pass" as cisgender. Despite having faced extensive violence, the participants in this sample were resilient, demonstrating many internal and external coping mechanisms and sources of strength. These findings can inform programs and services that target transgender women, providing participants with opportunities to build resilience and other coping mechanisms to buffer the harmful mental and physical health impacts of exposure to violence.

“I don't know much about providing pharmaceutical care to people who are transgender”: A qualitative study of experiences and attitudes of pharmacists

Background

Globally, with the increased visibility, the number of transgender people accessing healthcare services has risen in the last decade. Although pharmacists are required to provide equitable and respectful care to all patients, their experiences interacting with trans and gender-diverse (TGD) people and attitudes towards the provision of care are largely unknown.

Objectives

This study aimed to determine the experiences and attitudes of pharmacists providing care to TGD people in Queensland, Australia.

Methods

Within a transformative paradigm, this study used semi-structured interviews conducted in person, over the phone, or through the Zoom app. Data were transcribed and analyzed by applying the constructs of the Theoretical Framework of Accessibility (TFA).

Results

A total of 20 participants were interviewed. Analysis revealed all seven constructs across interview data, with affective attitude and self-efficacy being the most frequently coded constructs, followed by burden and perceived effectiveness. The least coded constructs included ethicality, intervention coherence, and opportunity cost. Pharmacists had positive attitudes towards providing care and interacting professionally with TGD people. Prime challenges in delivering care were being unaware of inclusive language and terminology, difficulty building trusted relationships, privacy and confidentiality at the pharmacy, inability to locate appropriate resources, and lack of training in TGD health. Pharmacists felt rewarded when they established rapport and created safe spaces. However, they requested communication training and education to improve their confidence in delivering care to TGD people.

Conclusion

Pharmacists demonstrated a clear need for further education on gender-affirming therapies and training in communication with TGD people. Including TGD care in pharmacy curricula and continuous professional development activities is seen as an essential step towards pharmacists improving health outcomes for TGD people.

Perceived Gender Transition Progress, Gender Congruence, and Mental Health Symptoms Among Transgender Adolescents

PURPOSE

Transgender adolescents (TGAs) have high risk for experiencing mental health problems, but little is known about how aspects of gender identity relate to their mental health symptoms. Evidence from child and adult samples of transgender individuals indicates making progress in gender transition milestones and higher levels of congruence between gender identity and gender expression are related to fewer mental health problems. We examined associations between perceived transition progress, gender congruence, and mental health symptoms in a diverse, nationwide sample of TGAs.

METHODS

TGAs (n = 1,943) participated in a cross-sectional online survey. Perceived gender transition progress, gender congruence, and depressive and anxiety symptoms were assessed. Path analysis was conducted to examine whether transition progress was related to mental health symptoms via higher levels of gender congruence.

RESULTS

Most TGAs had undertaken at least one social transition step (98%), but only 11% had taken medical transition steps. Higher gender congruence was associated with lower mental health symptoms. Greater transition progress was associated with higher gender congruence, and perceived transition progress evidenced negative indirect associations with mental health symptoms. TGAs identifying with binary identities (transmasculine and transfeminine youth) reported lower levels of transition progress and gender congruence compared to other subgroups of TGAs.

DISCUSSION

Higher levels of perceived transition progress and gender congruence are related to lower mental health symptoms among TGAs. Mental health interventions tailored to the unique developmental needs of TGAs are needed given high risk for mental health problems within this population, and interventions addressing transition progress and gender congruence should be examined.

Application of the network scale-up method to estimate the sizes of key populations for HIV in Singapore using online surveys

INTRODUCTION

Singapore lacks robust data on the sizes of the key populations that are most at risk for HIV. Using the network scale-up method for hidden or hard-to-reach populations, we estimate the sizes of five key populations-male clients of female sex workers (MCFSW), men who have sex with men (MSM), female sex workers (FSW), people who inject drugs (PWID) and transgender people-and profile the ages and ethnicities of respondents with the high-risk contacts they report knowing.

METHODS

We conducted a cross-sectional online survey between March and May 2019 (n = 2802) using a network scale-up instrument previously developed for Singapore. Participants were recruited using an existing panel and online advertising, and the sample reweighted by age, sex, ethnicity and education attained to represent the general adult population. We built a Bayesian hierarchical model to estimate the sizes of the five key populations for HIV in Singapore.

RESULTS

After adjustment, the sizes of the at-risk populations are estimated to be: 76,800 (95% credible interval [CI]: 64,200-91,800) MCFSW; 139,000 (95% CI: 120,000-160,000) MSM; 8030 (95% CI: 3980-16,200) FSW; 3470 (95% CI: 1540-7830) PWID and 18,000 (95% CI: 14,000-23,200) transgender people. Generally, men reported knowing more people in all the high-risk groups; older people reported knowing more MCFSW, FSW and transgender people; and younger people reported knowing more MSM. There was a bimodal effect of age on those who reported knowing more PWIDs: people in their 20s and 60s reported more contacts.

CONCLUSIONS

This study demonstrates that a size estimation study of hidden populations is quickly and efficiently scalable through using online surveys in a socially conservative society, like Singapore, where key populations are stigmatized or criminalized. The approach may be suitable in other countries where stigma is prevalent and where barriers to surveillance and data collection are numerous.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Mortality rates by gender and sexual orientation reveal a disproportionally high mortality among cisgender men of unknown sexual orientation and men who have sex with women in a cohort of people living with HIV in Rio de Janeiro, Brazil

BACKGROUND

Antiretroviral therapy use has led to a decline in HIV-related mortality yet disparities by gender and/or sexual orientation may exist. In this study, we estimated hazards of death in people living with HIV (PLWH) according to gender and sexual orientation.

METHODS

We included PLWH ≥ 18 years enrolled between 2000 and 2018 at INI/Fiocruz, Rio de Janeiro, Brazil. Participants were grouped as cisgender or transgender women, cisgender men who have sex with men (MSM) or men who have sex with women, or cisgender men with unknown sexual orientation. We assessed disparities in the hazard of death using Cox proportional hazards models.

RESULTS

Among 5,576 PLWH, median age at enrollment was 35 years, 39% were MSM, 28% cisgender women, 23% men who have sex with women, 5% transgender women, and 5% men with unknown sexual orientation. A total of 795 deaths occurred in 39,141 person-years of follow-up. Mortality rates per 1,000 person-years were: 82.4 for men with unknown sexual orientation, 24.5 for men who have sex with women, 18.3 for cisgender, 16.6 for transgender women, and 15.1 for MSM. Compared to MSM, men with unknown sexual orientation had the highest death hazard ratio (adjusted hazard ratio [aHR] 2.93, 95% confidence interval [CI] 2.35-3.81), followed by men who have sex with women (aHR 1.17, 95%CI 0.96, 1.43); death hazard ratios for cisgender and transgender women were not statistically different.

CONCLUSION

We observed disparities in the hazard of death for men with unknown sexual orientation and men who have sex with women despite universal access to antiretroviral therapy in Brazil. Future work should characterize and assist men with unknown sexual orientation with tailored policies and interventions. Increased hazard of death was not observed for transgender women, which probably results from interventions implemented in our service to reach, engage, retain, and support this population.

Sexual Orientation and Gender Identity-Related State-Level Policies and Perceived Health Among Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults in the United States

ObjectivesWe examined the associations between state-level policies and the health of lesbian, gay, bisexual, and transgender (LGBT) older adults. Methods: Using data from the 2018-2020 Behavioral Risk Factor Surveillance System surveys, we assessed physical and mental health by the tally of points for enacted LGBT-related policies (Low= <0-49.9% of possible points, High= 50-100% of possible points) in 10,032 sexual minority (i.e., lesbian, gay, and bisexual) and 1,072 transgender (non-sexual minority) adults aged 50 and older from 41 states. Results: Sexual minority adults in low tally states had greater odds of reporting fair or poor general health and 14 or more days of poor physical health in the past 30 days. Transgender participants in low tally states also had greater odds of reporting fair or poor general health. Discussion: Lesbian, gay, bisexual, and transgender adults have significantly greater risk of poor health if they live in a state with fewer LGBT anti-discriminatory policies enacted.

The impact of social violence on HIV risk for women in Colombia: A concurrent mixed methods study

Gender, violence, and migration structurally impact health. The Venezuelan humanitarian crisis comprises the largest transnational migration in the history of the Americas. Colombia, a post-conflict country, is the primary recipient of Venezuelans. The Colombian context imposes high levels of violence on women across migration phases. There is little information on the relationship between violence and HIV risk in the region and how it impacts these groups. Evidence on how to approach the HIV response related to Venezuela's humanitarian crisis is lacking. Our study seeks to 1) understand how violence is associated with newly reported HIV/AIDS case rates for women in Colombian municipalities; and 2) describe how social violence impacts HIV risk, treatment, and prevention for Venezuelan migrant and refugee women undergoing transnational migration and resettlement in Colombia. We conducted a concurrent mixed-methods design. We used negative binomial models to explore associations between social violence proxied by Homicide Rates (HR) at the municipality level (n = 84). The also conducted 54 semi-structured interviews with Venezuelan migrant and refugee women and key informants in two Colombian cities to expand and describe contextual vulnerabilities to HIV risk, prevention and care related to violence. We found that newly reported HIV cases in women were 25% higher for every increase of 18 homicides per 100,000, after adjusting for covariates. Upon resettlement, participants cited armed actors' control, lack of government accountability, gender-based violence and stigmatization of HIV as sources of increased HIV risk for VMRW. These factors impose barriers to testing, treatment and care. Social violence in Colombian municipalities is associated with an increase in newly reported HIV/AIDS case rates in women. Violence hinders Venezuelan migrant and refugee women's access and engagement in available HIV prevention and treatment interventions.

The Dobbs Decision and the Future of Occupational Health in the US

Access to abortion care has a profound impact on women's ability to participate in the workforce. In the US, restrictions on abortion care have waxed and waned over the years, including periods when abortion was broadly permitted across the nation for most pregnant people for a substantial proportion of pregnancy and times when restrictions varied across states, including states where abortion is banned for nearly all reasons. Additionally, access to abortion care has always been a reproductive justice issue, with some people more able to access this care than others even when it is structurally available. In June 2022, the US Supreme Court handed down the Dobbs v. Jackson Women's Health Organization, returning to states the ability to determine restrictions on abortion, including near-total bans on abortion. In this anthology, ten experts share their perspectives on what the Dobbs decision means for the future, how it will exacerbate existing, well-researched issues, and likely also create new challenges needing investigation. Some contributions are focused on research directions, some focus on implications for organizations, and most include both. All contributions share relevant occupational health literature and describe the effects of the Dobbs decision in context.

Addressing the Physical and Mental Impacts of Postsurgical Scarring Among Transgender and Gender Diverse People

Few studies have considered the diverse mental and physical health impacts of scarring among transgender and gender diverse (TGD) patients after medically necessary gender-affirming surgery (GAS). For some TGD patients, post-GAS scarring may exacerbate gender dysphoria. For others, it is a physical representation of authenticity. The dearth of research or validated instruments capturing the diversity of priorities and concerns pre- and post-GAS hinders providers' ability to deliver optimal clinical care throughout the gender-affirmation process and impedes progress for evidence-based policy change regarding post-GAS scar treatment. This article provides suggestions for future research directions to address post-GAS scar-related health needs.

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.