Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia

Opportunities for incorporating intersectionality into biomedical informatics

Many approaches in biomedical informatics (BMI) rely on the ability to define, gather, and manipulate biomedical data to support health through a cyclical research-practice lifecycle. Researchers within this field are often fortunate to work closely with healthcare and public health systems to influence data generation and capture and have access to a vast amount of biomedical data. Many informaticists also have the expertise to engage with stakeholders, develop new methods and applications, and influence policy. However, research and policy that explicitly seeks to address the systemic drivers of health would more effectively support health. Intersectionality is a theoretical framework that can facilitate such research. It holds that individual human experiences reflect larger socio-structural level systems of privilege and oppression, and cannot be truly understood if these systems are examined in isolation. Intersectionality explicitly accounts for the interrelated nature of systems of privilege and oppression, providing a lens through which to examine and challenge inequities. In this paper, we propose intersectionality as an intervention into how we conduct BMI research. We begin by discussing intersectionality's history and core principles as they apply to BMI. We then elaborate on the potential for intersectionality to stimulate BMI research. Specifically, we posit that our efforts in BMI to improve health should address intersectionality's five key considerations: (1) systems of privilege and oppression that shape health; (2) the interrelated nature of upstream health drivers; (3) the nuances of health outcomes within groups; (4) the problematic and power-laden nature of categories that we assign to people in research and in society; and (5) research to inform and support social change.

Examining the Performance of the Sexual Minority Adolescent Stress Inventory with Transgender and Gender-Diverse Youth and Sexual Minority Emerging Adults: A Methodological Study

Purpose: We examined the psychometric properties and criterion validity of the Sexual Minority Adolescent Stress Inventory (SMASI) among 730 sexual minority (SM) and transgender and gender-diverse (TGD) youth aged 14 to 24 years who participated in a human immunodeficiency virus study. Methods: We tested the factor structure of the global scale and subscales and measurement invariance across age, gender identity, sex assigned at birth, sexual identity, ethnoracial identity, and city. For criterion validity, we regressed mental health and substance use measures on the global scale. Results: The global scale had excellent fit (comparative fit index = 0.95) and high reliability (omega = 0.89). Subscale model fit was adequate. We confirmed invariance by gender identity and age and established criterion validity. Conclusion: The SMASI exhibits strong psychometric properties among SM emerging adults and TGD youth. Modifications could enhance the SMASI to better capture both sexual and gender minority stress among ethnoracial minority youth.

Structural transphobia is associated with psychological distress and suicidality in a large national sample of transgender adults

PURPOSE

Transgender adults face increasingly discriminatory laws/policies and prejudicial attitudes in many regions of the United States (US), yet research has neither quantified state-level transphobia using indicators of both, nor considered their collective association with transgender adults' psychological wellbeing, hindering the identification of this potential social determinant of transgender mental health inequity.

METHODS

We therefore used factor analysis to develop a more comprehensive structural transphobia measure encompassing 29 indicators of transphobic laws/policies and attitudes at the state level, which we linked to individual-level mental health data from a large national sample of 27,279 transgender adults (ages 18-100) residing in 45 US states and the District of Columbia (DC).

RESULTS

Controlling for individual- (i.e., demographics), interpersonal- (i.e., perceived discrimination), and state- (i.e., income inequality, religiosity) level covariates, transgender adults from US states with higher (vs. lower) levels of structural transphobia reported more severe past-month psychological distress and were more likely to endorse past-year and lifetime suicidal thoughts, plans, and attempts.

CONCLUSION

Findings provide novel evidence that state-level transphobic laws/policies and attitudes collectively shape a range of important mental health outcomes among transgender adults in the US. Multilevel intervention strategies, such as affirming mental health treatments, provider-training interventions, and supportive legislation, are needed to address structural transphobia's multifaceted nature and negative mental health consequences.

The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

'You have to trust their word': transmasculine experiences with sex partners and safety during the early COVID-19 outbreak

The early months of the SARS-CoV2 pandemic exacerbated health disparities for vulnerable populations, including transgender (trans) communities, creating unique challenges for navigating sex and dating. This paper aims to expand upon the current literature regarding transmasculine populations by capturing their lived experiences during this critical time. We interviewed 20 assigned female sex at birth (AFAB) adults of the transmasculine spectrum - men, nonbinary, and transmasculine individuals - about their social and sexual experiences in the USA in May and June 2020. Transcripts were analysed using an inductive thematic approach. We found that sex drive decreased and uncertainty about health risks increased. Some participants found alternate ways to date and hook-up that reduced their COVID-19 risk, such as engaging in online sex (e.g. sexting, dating apps). Others expressed discomfort using virtual platforms for both personal/work and sexual lives, along with nuanced feelings around being objectified, compared to pornography, and fetishised as trans bodies. COVID-related shutdowns of queer spaces also amplified pre-existing concerns about interpersonal safety and rejection. When seeking new partners, participants sought behavioural characteristics that instilled trust. Future public health communications can take advantage of safety and sexual health strategies already present in trans communities to bolster wellbeing in trans lives.

Quantitative approaches to measuring structural cisgenderism

There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.

A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary people experience substantial barriers to accessing healthcare, including prevention of HIV and other sexually transmitted infections (HIV/STI), due to structural inequities. We examined differences in insurance, HIV/STI prevalence, testing, and preexposure prophylaxis use among transgender and nonbinary people living in Washington State by race and ethnicity and gender.

METHODS

We pooled data from five 2019-2021 Washington State HIV/STI surveillance data sources to obtain a large and diverse sample of 1648 transgender and nonbinary participants. We calculated the risk difference (RD) for each outcome and used Poisson regression to estimate a surrogate measure of additive interaction-attributable proportion (AP)-that measures the proportion of the excess prevalence of the outcome observed at the intersection of gendered and racialized experience, beyond that expected from gender or race and ethnicity alone.

RESULTS

Participants reported overall high levels of poverty (29% incomes <$15,000 and 7% unstable housing). Certain groups, especially racial/ethnic minority transgender women, were disproportionately impacted by HIV/STIs (RDs from 20% to 43% and APs from 50% to 85%) and less likely to currently have insurance (RDs from 25% to 39% and APs from 74% to 93%) than that expected based on gendered or racialized experience alone.

CONCLUSIONS

Our findings highlight the heterogeneity in insurance access, HIV/STI positivity, and prevention utilization within transgender communities. We observed that a large proportion of increased HIV/STI prevalence among racial/ethnic minority transgender women was attributable to the intersection of gender and race and ethnicity. Our findings highlight the importance of trans-inclusive models of HIV/STI prevention that address multilevel barriers rooted in cissexism and structural racism.

Pre-exposure Prophylaxis Use and Discontinuation in a Federally Qualified Health Center in a Mexico-US Border City

BACKGROUND

Latino men who have sex with men (MSM) experience disproportionately high rates of HIV diagnoses in the United States. Pre-exposure prophylaxis (PrEP) use is critical to reduce this inequity, but PrEP awareness, access, and use are low among Latino MSM. This study aims to describe patterns of PrEP persistence and discontinuation among predominately Latino MSM accessing PrEP in a federally qualified health center (FQHC) in El Paso, Texas.

METHODS

This retrospective cohort comprised individuals who were eligible for PrEP at a FQHC in El Paso, Texas, between January 30, 2019, and August 15, 2021. We defined hierarchical categories of PrEP use and discontinuation, which was defined as more than 120 days between PrEP visits. We used Kaplan-Meier survival plots to estimate median time to first PrEP discontinuation.

RESULTS

There were 292 patients evaluated for PrEP; 91% were Latino. The majority of PrEP patients (70%, 205/292) experienced any PrEP discontinuation, and the median time to first PrEP discontinuation was 202 days (95% CI: 179-266). The proportion of patients who remained on PrEP at 3 months after initiation was 82% (95% CI: 76%, 87%) and at 6 months after initiation was 55% (95% CI: 46%, 62%).

CONCLUSION

While 3-month PrEP retention was high in this predominately Latino MSM patient population, PrEP discontinuation was common. Interventions that enhance longer-term persistence and support for restarting PrEP are needed to reduce the persistent ethnoracial disparities in HIV incidence.

HIV Incidence Among Individuals Accessing Pre-Exposure Prophylaxis in Jackson, Mississippi

Although pre-exposure prophylaxis (PrEP) is an efficacious biomedical intervention, the effectiveness of same-day PrEP programs has not been widely studied. We utilized data from three of the four largest PrEP providers in Mississippi from September 2018 to September 2021 linked to the Mississippi State Department of Health's Enhanced HIV/AIDS reporting system. HIV diagnosis was defined as testing newly positive for HIV at least 2 weeks after the initial PrEP visit. We calculated the cumulative incidence and incidence rate of HIV per 100 person-years (PY). Person-time was calculated as time from the initial PrEP visit to (1) HIV diagnosis or (2) December 31, 2021 (HIV surveillance data end date). We did not censor individuals if they discontinued PrEP to obtain an estimate of PrEP effectiveness rather than efficacy. Among the 427 clients initiating PrEP during the study period, 2.3% [95% confidence interval (CI): 0.9-3.8] subsequently tested positive for HIV. The HIV incidence rate was 1.18 per 100 PY (95% CI: 0.64-2.19) and median time to HIV diagnosis after the initial PrEP visit was 321 days (95% CI: 62-686). HIV incidence rates were highest among transgender and nonbinary individuals [10.35 per 100 PY (95% CI: 2.59-41.40)] compared with cisgender men and women, and among people racialized as Black [1.45 per 100 PY (95% CI: 0.76-2.80)] compared with White and other racialized groups. These findings indicate a need for more clinical and community interventions that support PrEP persistence and restarts among those at high risk of HIV acquisition.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic.

RECENT FINDINGS

While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Critical Perspectives on Expanding Racial/Ethnic Diversity in the HIV Research Workforce: Comorbidities and Mentoring

HIV-related comorbidities in underrepresented minority populations are reframed to include the co-occurring problems of systemic and structural barriers, within the mentoring context as a buffer and as action-oriented. This framework is discussed to improve racial and ethnic minority diversity in the research workforce from the perspectives of HIV comorbidities and mentoring. An integrated and coordinated approach to HIV-related comorbidities and inequities may be helpful when combined with research on the social-structural contributions as drivers to diversify the research workforce. We emphasize how these key research issues (a) provide a platform for training and retraining a highly motivated, diverse workforce and (b) facilitate the empowerment of these trained individuals to conduct rigorous scientific research on social-structural factors to mitigate the effects of these comorbidities. We conclude that a diverse research workforce is necessary but insufficient for improving training-related outcomes or reducing comorbidity effects. Additional considerations are warranted that include systemic approaches and changes at the structural and institutional levels.

Structural racism theory, measurement, and methods: A scoping review

Introduction

Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work.

Methods

This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022.

Results

A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section.

Discussion

This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.

Rare exemplars and missed opportunities: Intersectionality within current sexual and gender diversity research and scholarship in psychology

Using intersectionality as our critical analytical framework, we examined 22 articles on sexual and gender diversity (SGD) published in peer-reviewed psychology journals between January and June 2022 to: (1) identify their engagement with intersectionality's core themes; and (2) highlight key findings and directions for future intersectional SGD research. Our review includes 12 theoretical and empirical articles that addressed a breadth of topics such as intersectional stigma/discrimination, gendered racism, minority stress, and intersectional ableism. This review highlights opportunities within intersectional SGD research in psychology to provide a needed corrective to the discipline's tradition of individualistic, single-axis research focused on predominantly White, cisgender and heterosexual people, and attend to intersectionality's focus on intersecting power relations and commitments to social justice.