Using a two-step method to measure transgender identity in Latin America/the Caribbean, Portugal, and Spain

Disentangling gender, sex, and biology: a mixed methods study of gender identity data collection tools

OBJECTIVES

We used community-based mixed methods to test whether transgender and gender diverse (TGD) people preferred gender identity questions developed by community members over current questions in use and generate hypotheses about data collection preferences.

METHODS

We interviewed twenty TGD adults in English and Spanish, asking them to rate and discuss their responses to questions. We analyzed quantitative data with descriptive statistics and qualitative data with template analysis, then integrated them.

RESULTS

More participants preferred gender identity questions that were currently in use. Themes: 1) TGD participants find questions about "gender" and related terminology unclear because of conflations of sex, gender, and other constructs. 2) TGD participants resist cisgenderism in questions about gender identity. 3) TGD people desire questions that allow for autonomy, privacy, and safety. 4) Contextual factors, particularly safety, influence whether and how TGD people answer questions about gender and sex.

CONCLUSIONS

TGD people have varied concepts of sex and gender and preferences about data collection. Future research should investigate the impacts of disentangling gender, sex, and biological factors, which could decrease stigma for TGD people.

PRACTICE IMPLICATIONS

Medical care that disentangles gender, sex, and biological factors could improve data collection effectiveness and the safety of TGD people.

Gender Minority Stressors and Psychological Distress Among Chinese Transgender and Gender Diverse People: Variable-Centered, Person-Centered, and Psychological Network Approaches

Mental health disparities in transgender and gender diverse (TGD) populations call for more research examining gender minority stressors (GMS) as antecedents to their psychological distress, especially for the long-underrepresented groups living in conservative societies towards gender minorities. Furthermore, some questions remain underexamined, including the relative, independent influences of various GMS on TGD people's mental well-being (i.e., uniqueness of each stressor); how these stressors would configurate with each other in distinctive patterns to characterize subgroups of TGD people (i.e., beyond-average heterogeneity); and how these stressors would constitute a psychological network and vary in their centrality in that network (i.e., holistic complexity). To narrow such gaps, we examined the links between GMS and TGD people's psychological distress, using survey data collected in 2023 from 410 Chinese TGD people (Meanage = 22.33 years, SD = 4.27; 306 transgender, 70 non-binary/gender-queer/gender-fluid, 26 agender/gender-neutral, 3 intersex, and 5 others). We approached such links from three perspectives. First, variable-centered analyses indicated that while different GMS were considered simultaneously, internalized transphobia, preoccupation with gender dysphoria, and gender-related victimization were uniquely associated with psychological distress. Second, person-centered analyses yielded a 3-profile solution. Psychological distress varied systematically across profiles. Last, network analyses revealed a 3-cluster structure: Distal, Proximal Internal, and TGD-Specific Stressors. Preoccupation with gender dysphoria was the most central node. These findings contribute to a more nuanced understanding of the implications of GMS for TGD people's mental well-being. GMS related to internal struggles with gender identity might be among the central intervention targets to prevent/reduce TGD people's psychological distress.

Male-to-female transgenders demonstrated unique perspectives on perceived facial attractiveness and orthognathic surgery need

PURPOSE

The esthetic preference and decision concerning undergoing orthognathic surgery in the transgender population have not been reported. The aims of this study were to examine the influence of the sagittal mandibular position on the esthetic perception and perceived surgery need in male-to-female transgenders (MTFTs) compared with male and female laypeople.

MATERIALS AND METHODS

A questionnaire study was performed by male-to-female transgender, male and female laypeople. Three-dimensional black & white male and female facial images with facial contour angle (FCA) of 3°, 1°, 5°, 9°,13°, 17°, and 21° were shown to the participants. The participants scored the images' perceived facial attractiveness using visual analog scales (VAS) and indicated whether orthognathic surgery was needed.

RESULTS

The participants included 85 MTFTs, 85 males, and 85 females. The results revealed that there were significant differences in the VAS scores between the MTFT and male participants. The MTFTs rated the male images with prognathism of 1° and -3°FCA in significantly lower scores compared with the males (P = 0.033, P = 0.010). Female images with prognathism 1°FCA was rated by the MTFTs in significantly lower scores compared with the males (P = 0.041). A significantly higher number of surgery needs was found in the MTFTs compared with the other groups.

CONCLUSIONS

Gender influences esthetic perception and the decision to undergo orthognathic surgery. MTFTs have a unique perspective on facial esthetics, being more desirous of surgery than males and females. Clinicians should be aware of the ideal expectation in facial esthetics in MTFTs.

The Associations Between Gender Minority Stressors and PTSD Symptom Severity Among Trauma-Exposed Transgender and Gender Diverse Adults

This study investigates associations between minority stressors, traumatic stressors, and post-traumatic stress disorder (PTSD) symptom severity in a sample of transgender and gender diverse (TGD) adults. We utilized surveys and clinical interview assessments to assess gender minority stress exposures and responses, and PTSD. Our sample (N = 43) includes adults who identified as a minoritized gender identity (i.e., 39.5% trans woman or woman, 25.6% trans man or man, 23.3% genderqueer or nonbinary, 11.6% other identity). All participants reported at least one traumatic event (i.e., life threat, serious injury, or sexual harm). The most common trauma events reported by the sample were sexual (39.5%) and physical violence (37.2%), with 40.9% of participants anchoring their symptoms to a discrimination-based event. PTSD symptom severity was positively correlated with both distal (r = 0.36, p = .017) and proximal minority stressors (r = 0.40, p < .01). Distal minority stress was a unique predictor of current PTSD symptom severity (b = 0.94, p = .017), however, this association was no longer significant when adjusting for proximal minority stress (b = 0.18, p = 0.046). This study suggests that minority stress, especially proximal minority stress, is associated with higher PTSD symptom severity among TGD adults.

The anti-gender threat: An ethical, democratic, and scientific imperative for NIH research/ers

Anti-gender campaigns in the United States and globally have promoted policies and legislation that significantly limit bodily autonomy for women, transgender, and nonbinary people. This attack on the human rights of women and gender-diverse communities not only reflects implicit and explicit bias but also detrimentally impacts population health and well-being. We outline the domestic and global rise of anti-gender campaigns and their deep historical connections to broader forms of discrimination and inequality to argue that there is an ethical, democratic, and scientific imperative to more critically center and contextualize gender in health research. While the inclusion of gender as a complex concept in research design, implementation, and dissemination is important, we emphasize that gender inequities must be understood as inextricable from other systems of discrimination and exclusion. To that end, this commentary outlines two actions: for researchers to advance critical approaches to gender as part of a broader landscape of discrimination, and for the US National Institutes of Health to integrate both sex and gender into funded research.

Examining the Risks of Multiple Types of Interpersonal Victimization for Transgender and Gender Non-Conforming College Students

Recent research has shown that transgender and gender non-conforming (TGNC) individuals are at risk of experiencing interpersonal violence, yet there may be differences within this group and across victimization types. The current study examined rates of seven types of interpersonal victimization based on six gender identities (cisgender women, cisgender men, trans women, trans men, nonbinary, and another identity) among a national study of college students. Data from the Spring 2021 American College Health Association's National College Health Assessment III (ACHA-NCHA III), a national-level study of U.S. college students, were used. We examined the association between gender identity and seven types of interpersonal violence victimization (violent victimization, sexual victimization, intimate partner violence victimization, stalking, bullying, microaggression, and discrimination) that occurred within the past 12 months. Logistic regression analyses were performed to examine if, when controlling for competing factors, gender identity was associated with an increase in the expected odds of victimization for each victimization type. Analyses revealed that TGNC college students reported experiencing a greater amount of all seven types of victimization compared to cisgender college students. These findings corroborate previous research indicating that rates of interpersonal violence are higher among TGNC college students compared to those who identify as cisgender, even after controlling for sexual orientation, related demographic factors, and substance use. Findings from the current study suggest that there are differences within individuals who identify as TGNC in terms of their risk for interpersonal victimization and that rates differ across victimization types. More work is needed to provide tailored prevention programming for TGNC college students.

Will all youth answer sexual orientation and gender-related survey questions? An analysis of missingness in a large U.S. survey of adolescents and young adults

Some researchers and clinicians may feel hesitant to assess sexual orientation and gender-related characteristics in youth surveys because they are unsure if youth will respond to these questions or are concerned the questions will cause discomfort or offense. This can result in missed opportunities to identify LGBTQ+ youth and address health inequities among this population. The aim of this study was to examine the prevalence and sociodemographic patterns of missingness among survey questions assessing current sexual orientation, gender identity and expression (SOGIE), and past change in sexual orientation (sexual fluidity) among a diverse sample of U.S. youth. Participants (N = 4,245, ages 14-25 years; 95% cisgender, 70% straight/heterosexual, 53% youth of color), recruited from an online survey panel, completed the Wave 1 survey of the longitudinal Sexual Orientation Fluidity in Youth (SO*FLY) Study in 2021. Current SOGIE, past sexual fluidity, and sociodemographic characteristics were assessed for missingness. Overall, 95.7% of participants had no missing questions, 3.8% were missing one question, and 0.5% were missing ≥ 2 questions. Past sexual fluidity and assigned sex were most commonly missing. Sociodemographic differences between participants who skipped the SOGIE questions and the rest of the sample were minimal. Missingness for the examined items was low and similar across sociodemographic characteristics, suggesting that almost all youth are willing to respond to survey questions about SOGIE. SOGIE and sexual fluidity items should be included in surveys and clinical assessments of youth to inform clinical care, policy-making, interventions, and resource development to improve the health of all youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sexual orientation and gender identity measures and viral suppression for people living with HIV: a protocol for a population-based cohort study

INTRODUCTION

The measure of sexual orientation and gender identity (SOGI) data in electronic health records (EHR) has been critical for addressing health disparities and inequalities, especially for HIV care. Given that gender and sexual minorities (eg, transgender, men who have sex with men and intersex) are key groups in people living with HIV (PLWH), SOGI data can facilitate a more accurate understanding about the HIV outcomes (eg, viral suppression) among this key group and then lead to tailored therapeutic services. The two-step SOGI collection method as an emerging gender measurement can be used to measure SOGI status in medical settings. Using the statewide cohort of PLWH in South Carolina (SC), this project aims to: (1) integrate statewide PLWH cohort data with their birth certificate data to evaluate SOGI measurements from multiple EHR sources; and (2) examine differences in viral suppression based on SOGI measurements.

METHODS AND ANALYSIS

Our EHR database includes several HIV data sources with patients' gender information, such as SC Department of Health and Environmental Control Centre (DHEC), Health Sciences South Carolina (HSSC) and Prisma as well as birth certificate data to retrieve the sex at birth. The SC Enhanced HIV/AIDS Reporting System (e-HARS) from DHEC will provide longitudinal viral load information to define a variety of viral suppression status. Datasources like the SC office of Revenue and Fiscal Affairs (RFA) will extract longitudinal EHR clinical data of all PLWH in SC from multiple health systems; obtain data from other state agencies and link the patient-level data with county-level data from multiple publicly available data sources.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board at the University of South Carolina (Pro00129906) as a Non-Human Subject study. The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media.

A Relative Value Unit-Based Model for Targeted Nipple-Areola Complex Neurotization in Gender-Affirming Mastectomy

Background

For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple-areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity.

Methods

A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included.

Results

A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2-111.5) without neurotization and 154.2 minutes (95% CI, 139.9-168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute.

Conclusions

Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

Access to healthcare among transgender women living with and without HIV in the United States: associations with gender minority stress and resilience factors

BACKGROUND

Transgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States.

METHODS

This study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status.

RESULTS

Higher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access.

CONCLUSIONS

Gender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.

Transgender identity in young people and adults recorded in UK primary care electronic patient records: retrospective, dynamic, cohort study

Objectives

To quantify the change in proportion of young people and adults identified as transgender in UK primary care records and to explore whether rates differ by age and socioeconomic deprivation.

Design

Retrospective, dynamic, cohort study.

Setting

IQVIA Medical Research Data, a database of electronic primary care records capturing data from 649 primary care practices in the UK between 1 January 2000 and 31 December 2018.

Participants

7 064 829 individuals aged 10-99 years, in all four UK countries.

Main outcome measures

Diagnostic codes indicative of transgender identity were used. Sex assigned at birth was estimated by use of masculinising or feminising medication and procedural/diagnostic codes.

Results

2462 (0.03%) individuals had a record code indicating a transgender identity. Direction of transition could be estimated for 1340 (54%) people, of which 923 were assigned male at birth, and 417 were assigned female at birth. Rates of recording in age groups diverged substantially after 2010. Rates of the first recording of codes were highest in ages 16-17 years (between 2010 and 2018: 24.51/100 000 person years (95% confidence interval 20.95 to 28.50)). Transgender codes were associated with deprivation: the rate of the first recording was 1.59 (95% confidence interval 1.31 to 1.92) in the most deprived group in comparison with the least deprived group. Additionally, the rate ratio of the proportion of people who identified as transgender was 2.45 (95% confidence interval 2.28 to 2.65) in the most deprived group compared with the least deprived group. Substantial increases were noted in newly recorded transgender codes over time in all age groups (1.45/100 000 person years in 2000 (95% confidence interval 0.96 to 2.10) to 7.81/100 000 person years in 2018 (6.57 to 9.22)). In 2018, the proportion of people with transgender identity codes was highest in the age groups 16-17 years (16.23 per 10 000 (95% confidence interval 12.60 to 20.57)) and 18-29 years (12.42 per 10 000 (11.06 to 13.90)).

Conclusion

The rate of transgender identity recorded in primary care records has increased fivefold from 2000 to 2018 and is highest in the 16-17 and 18-29 age groups. Transgender diagnostic coding is associated with socioeconomic deprivation and further work should investigate this association. Primary and specialist care should be commissioned accordingly to provide for the gender specific and general health needs of transgender people.

HIV prevalence in transgender populations and cisgender men who have sex with men in sub-Saharan Africa 2010-2022: a meta-analysis

Introduction

The Global AIDS Strategy 2021-2026 calls for equitable and equal access to HIV prevention and treatment programmes for all populations to reduce HIV incidence and end HIV/AIDS as a public health threat by 2030. Transgender populations (TGP), including transmen (TGM) and transwomen (TGW) are populations that have been marginalised and are at high risk of HIV infection in sub-Saharan Africa (SSA). Limited surveillance data on HIV among TGP are available in the region to guide programmatic responses and policymaking. Surveillance data on cisgender men who have sex with men (cis-MSM) are comparatively abundant and may be used to infer TGP HIV prevalence.

Methods

Data from key population surveys conducted in SSA between 2010-2022 were identified from existing databases and survey reports. Studies that collected HIV prevalence on both TGP and cis-MSM populations were analysed in a random effect meta-analysis to estimate the ratio of cis-MSM:TGW HIV prevalence.

Results

Eighteen studies were identified encompassing 8,052 TGW and 19,492 cis-MSM. TGW HIV prevalence ranged from 0-71.6% and cis-MSM HIV prevalence from 0.14-55.7%. HIV prevalence in TGW was 50% higher than in cis-MSM (prevalence ratio (PR) 1.50 95% CI 1.26-1.79). TGW HIV prevalence was highly correlated with year/province-matched cis-MSM HIV prevalence (R2 = 0.62), but poorly correlated with year/province-matched total population HIV prevalence (R2 = 0.1). Five TGM HIV prevalence estimates were identified ranging from 1-24%. Insufficient TGM data were available to estimate cis-MSM:TGM HIV prevalence ratios.

Conclusion

Transgender women experience a significantly greater HIV burden than cis-MSM in SSA. Bio-behavioural surveys designed and powered to measure determinants of HIV infection, treatment coverage, and risk behaviours among transgender populations, distinct from cis-MSM, will improve understanding of HIV risk and vulnerabilities among TGP and support improved programmes.

A scoping review of the structuring of questions about sexual orientation and gender identity

The purpose of this scoping review is to map the extent of the current research on how to best structure questions asking respondents to self-identify their sexual orientation and gender identity and to ascertain what further issues about measurement need to be explored. Using the Arksey and O'Malley framework for scoping reviews, 52 articles describing primary research about how to structure sexual orientation and gender identity (SOGI) questions, published in the years 2000-2021, were identified and analyzed. The domain of sexuality being asked about (e.g., self-label vs. behavior) needs to be clarified, and gender identity should be asked through a multipart item differentiating current identity from the sex assigned at birth. The terms used in the response options should be defined and may vary based on the study population or context. Contrary to expectations given the wide range of question formats currently being used in the field, there is considerable consensus around the basic tenets for structuring questions designed to assess SOGI dimensions.

Gender Identity Change Efforts Are Associated with Depression, Panic Disorder, and Suicide Attempts in South Korean Transgender Adults

Purpose

Gender identity change efforts (GICEs), sometimes referred to as "conversion therapy," are considered pseudoscientific and unethical practices that are not supported by the existing scientific literature. However, a substantial portion of transgender people face such practices during their lives. We assessed lifetime exposure to GICEs and its associations with mental health indicators among transgender adults in South Korea.

Methods

We analyzed a nationwide cross-sectional survey of 566 Korean transgender adults conducted in October 2020. Lifetime exposure to GICEs was classified as follows: "never had GICE-related experiences," "received a referral, but did not undergo GICEs," and "undergone GICEs." We assessed mental health indicators, including past-week depressive symptoms; medical diagnosis or treatment of depression and panic disorder; and past 12-month suicidal ideation, suicide attempts, and self-harm.

Results

Of the total participants, 12.2% had "received a referral, but did not undergo GICEs," and 11.5% had "undergone GICEs." Compared with those who had "never had GICE-related experiences," participants who had "undergone GICEs" showed significantly higher prevalence of depression (adjusted prevalence ratio [aPR]=1.34, 95% confidence interval [CI]=1.11-1.61), panic disorder (aPR=2.52, 95% CI=1.75-3.64), and suicide attempts (aPR=1.73, 95% CI=1.10-2.72). However, we did not find significant associations between having "received a referral, but did not undergo GICEs" and mental health indicators.

Conclusion

Given our findings suggest that lifetime exposure to GICEs may harm transgender adults' mental health, legal restrictions should be imposed to ban GICEs in South Korea.

Provision of cervical screening for transmasculine patients: a review of clinical and programmatic guidelines

BACKGROUND

Most cervical cancer can be prevented through routine screening. Disparities in uptake of routine screening therefore translate into disparities in cervical cancer incidence and outcomes. Transmasculine people including transgender men experience multiple barriers to cervical screening and their uptake of screening is low compared with cisgender women. Comprehensive evidence-based guidelines are needed to improve cervical screening for this group.

METHODS

We searched for and synthesised clinical and programmatic guidelines for the provision of cervical screening for transmasculine patients.

FINDINGS

The guidelines offer recommendations addressing: (1) reception, check-in and clinic facilities; (2) patient data and invitation to screening; (3) improving inclusion in screening programmes; and (4) sexual history taking, language and identity. Guidelines offer strategies for alleviating physical and psychological discomfort during cervical screening and recommendations on what to do if the screening procedure cannot be completed. Most of the guidelines were from and for high-income countries.

DISCUSSION

The evidence base is limited, but existing guidelines provide recommendations to ensure life-saving screening services are available to all who need them. We were only able to identify one set of guidelines for a middle-income country, and none for low-income countries. We encourage the involvement of transmasculine people in the development of future guidelines.

Health(care) matters: where do the transgender individuals of Kashmir situate themselves?

While employing a phenomenological perspective, the present study aimed to explore the varied experiences of transgender individuals in Kashmir, concerning their health-seeking behavior, and the constraints they face while accessing healthcare resources on a day-to-day basis in their life world. Participants were recruited through the purposive and snowball sampling strategies and the sufficiency of sample size was determined by data saturation. Data were collected using face-to-face in-depth interviews and analyzed through Colaizzi's procedure of extracting recurrent themes and their interwoven relationships in qualitative research. Three main themes of awareness and the preferences for healthcare, gender identity and persistent stigmatization in care settings, and intra-community support and the resultant caregiving were prominent. Results of the study revealed that the transgender individuals in Kashmir experience inappropriate health-seeking behaviour primarily due to their unawareness regarding health, diseases and public healthcare programs/schemes, financial constraints, social exclusion, improper support and social stigma. They often prefer treating their health issues, mostly through local pharmacies or patent medicine vendors (PMVs), instead of visiting the medical professionals in the organized sector. Moreover, in many instances, they were also found to delay their decisions to seek care or simply decided to remain far from any medical intervention. As a result, the transgender individuals in Kashmir usually experience underutilization of formal healthcare services, which undermines their right to proper health and well-being.

A scoping review of survey research with gender minority adolescents and youth in low and middle-income countries

BACKGROUND

Survey data that categorizes gender identity in binary terms and conflates sex and gender limits knowledge around the experience of gender minority populations, whose gender identity or expression does not align with the sex they were assigned at birth. In this review, we outline the existing survey research on the experience of a gender minority demographic for whom there is particularly limited data: adolescents and youth in low and middle-income countries (LMICs).

METHODS

This paper is a scoping review of peer-reviewed articles, published in English, that use survey data to examine the experience of gender minority adolescents and youth in LMICs. We conducted a search on two major databases using key terms related to gender identity, adolescence and youth, and country and region. This search yielded 385 articles. Following a team-conducted review, we retained 33 articles for the final analysis.

RESULTS

Our review shows that surveys with adolescents and youth in LMICs are increasingly including questions and taking sampling approaches that allow gender minority populations to be visible in survey data. Surveys that do so are largely focused in upper middle-income countries (n = 24), rather than lower middle-income or low-income countries, with South East Asia a notable sub-region of focus (n = 15). Sexual health, mental health, and violence are key topics of interest. Most of the surveys rely on some form of network-driven sampling focused on sexual and/or gender minorities (n = 22). The studies vary in how they ask about gender identity, both in terms of question formulation and the answer categories that are offered, as well as the extent to which they describe the questions in the article text.

CONCLUSIONS

This review reveals a growing body of work that provides important insights into the experiences of gender minority adolescents and youth in LMICs. More studies could integrate these approaches, but it must be done in a way that is thoughtful about cultural and political context. Given the relatively nascent nature of such research, we encourage scholars to continue providing details on methodology, including around participant recruitment and the development of gender identity questions. This information would be valuable for researchers seeking to better include gender minorities and their experiences in survey research, but who might be daunted methodologically.

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

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

Sex and Gender Multidimensionality in Epidemiologic Research

Along with age and race, sex has historically been a core stratification and control variable in epidemiologic research. While in recent decades research guidelines and institutionalized requirements have incorporated an approach differentiating biological sex from social gender, neither sex nor gender is itself a unidimensional construct. The conflation of dimensions within and between sex and gender presents a validity issue wherein proxy measures are used for dimensions of interest, often without explicit acknowledgement or evaluation. Here, individual-level dimensions of sex and gender are outlined as a guide for epidemiologists, and 2 case studies are presented. The first case study demonstrates how unacknowledged use of a sex/gender proxy for a sexed dimension of interest (uterine status) resulted in decades of cancer research misestimating risks, racial disparities, and age trends. The second illustrates how a multidimensional sex and gender framework may be applied to strengthen research on coronavirus disease 2019 incidence, diagnosis, morbidity, and mortality. Considerations are outlined, including: 1) addressing the match between measures and theory, and explicitly acknowledging and evaluating proxy use; 2) improving measurement across dimensions and social ecological levels; 3) incorporating multidimensionality into research objectives; and 4) interpreting sex, gender, and their effects as biopsychosocial.

A Scoping Review of Health Outcomes Among Transgender Migrants

Purpose

Transgender people constitute diverse populations who experience a range of adverse health outcomes. Despite increasing awareness of adverse health outcomes among migrant populations, there has been a dearth of studies focused on the health of transgender migrants. The goal of this scoping review was to describe common themes and empirical trends in research on the health of transgender migrants and identify gaps for future research and programming.

Methods

Using a systematic review protocol, we searched PubMed, Embase, Scopus, PsycINFO, CINAHL, and Web of Science with a combination of terms to identify empirical articles that examined health outcomes among transgender migrants. The search included studies published as of May 2019.

Results

Twenty of 1666 identified records met inclusion criteria. All studies were cross-sectional, and 50% were quantitative designs, 45% were qualitative designs, and 5% were mixed-methods designs. The majority reported on sexually transmitted infections (55%), violence (40%), and mental health (35%). Qualitative studies were generally high quality, while many quantitative studies had high risk of bias. While some adverse health outcomes may abate, stigmatizing social conditions continue to impact transgender migrant's health postmigration.

Conclusions

Anti-transgender and anti-immigrant stigma may contribute to adverse health outcomes for transgender migrants. Additional research using rigorous inclusive methods to survey a broader range of health domains is needed. The lives of transgender migrants are continuously upended by oppressive policies; therefore, it is vital to continue to expand the breadth of transgender health research.

Gay and lesbian health agendas

The aim of this study was to validate gay and lesbian health agendas pushed by organizations representing these groups. To this end, we created a health agenda matrix based on 25 narratives of representatives from 16 different gay and lesbian groups in ten state capitals in Brazil collected in another study. Each agenda was considered to have reached consensus when the mean score was equal to or greater than seven and SD was equal to or less than two. The validated agendas addressed the following themes: physical and psychological violence; the care needs of lesbians related to uterine and breast cancer; mental health; training of health care professionals; AIDS prevention and care; assisted reproduction for lesbians; the urological and proctological care needs of gays; development of informative material on general health; and information and treatment of sexually transmitted diseases. It is concluded that gay and lesbian movements are potentially important actors in the public health arena, not only proposing important issues that need to be considered in public policies and actions to improve health care for LGBT people, but also mediating between health professionals and homosexuals seeking health services.

Gay and lesbian health agendas

Abstract The aim of this study was to validate gay and lesbian health agendas pushed by organizations representing these groups. To this end, we created a health agenda matrix based on 25 narratives of representatives from 16 different gay and lesbian groups in ten state capitals in Brazil collected in another study. Each agenda was considered to have reached consensus when the mean score was equal to or greater than seven and SD was equal to or less than two. The validated agendas addressed the following themes: physical and psychological violence; the care needs of lesbians related to uterine and breast cancer; mental health; training of health care professionals; AIDS prevention and care; assisted reproduction for lesbians; the urological and proctological care needs of gays; development of informative material on general health; and information and treatment of sexually transmitted diseases. It is concluded that gay and lesbian movements are potentially important actors in the public health arena, not only proposing important issues that need to be considered in public policies and actions to improve health care for LGBT people, but also mediating between health professionals and homosexuals seeking health services.

Exploring HIV risk behavior and sexual/gender identities among transgender women and their sexual partners in Peru using respondent-driven sampling

HIV prevalence is high among transgender women, but little is known about cisgender men who have sex with transgender women (MSTW). The objective of this study was to investigate characteristics and behavior of MSTW compared to transgender women and men who have sex with men (MSM) using a modified respondent-driven sampling design. Seed participants completed a survey and invited up to three sex partners. Forward recruitment continued in waves through the referral of sex partners. Cross-sectional data were assessed using mixed effects models. From February to July 2018, 479 participants in Lima, Peru enrolled (n = 199 transgender women, n = 196 MSTW, and n = 45 MSM). MSTW behavior and identity differed significantly from that of transgender women and MSM. MSTW primarily identified as bisexual (69%) or heterosexual (15%) and only 6% reported male partners. Insertive condomless anal intercourse was reported by 61% of MSTW; 46% did not know their HIV serostatus. Compared to MSTW without male partners, those with recent male partners were more likely to sell sex (OR 15.7, 95% CI 4.1-60.5), and report condomless receptive anal intercourse (OR 89.0, 95% CI 19.1-414.8). This evidence suggests that MSTW are a distinct population from MSM, and highlights the critical need to include MSTW in HIV research and interventions.

Uncertainty and Confusion Regarding Transgender Non-discrimination Policies: Implications for the Mental Health of Transgender Americans

Introduction

Recent policies have restricted the rights of the US transgender people; there is a need to explore transgender people's knowledge and attitudes regarding such policies and related mental health.

Methods

In 2019, 580 transgender adults living in the Northeastern US completed a survey assessing demographics, knowledge/attitudes toward transgender-related policies, and mental health. Multivariable logistic regression models, adjusted for age, gender, race, and prior abuse, were fit to examine the association of concerns about the implementation of discriminatory policies and depression, anxiety, and post-traumatic stress disorder (PTSD).

Results

Many participants were confused about the status of federal and state protections for transgender people, and 48.4% were concerned that their state would pass policies that took away transgender rights. In adjusted models, compared to participants who were not concerned, those who were concerned about the enactment of state-level, anti-transgender policies had greater odds of depression, anxiety, and PTSD (p < 0.05).

Conclusions

Our findings highlight the uncertainty around changing policies and potential mental health implications as well as the need to ensure legal protections for transgender Americans.

Policy Implications

There are several pending lawsuits seeking to overturn Trump-era policies that restrict the rights of transgender individuals. At the same time, lawmakers in several states are pushing anti-transgender legislation. Findings from this study can be cited as part of future and ongoing legal and legislative efforts from advocates seeking to ensure equal protections for transgender people under state and federal law.

Associations of gender identity with sexual behaviours, social stigma and sexually transmitted infections among adults who have sex with men in Abuja and Lagos, Nigeria

Introduction

Sexual and gender minority populations are disproportionately affected by the global syndemic of HIV and other sexually transmitted infections (STIs). We hypothesized that transgender women (TGW) and non‐binary individuals in Nigeria have more STIs than cis‐gender men who have sex with men (cis‐MSM), and that experiences of stigma and sexual practices differ between these three groups.

Methods

From 2013 to 2020, TRUST/RV368 enrolled adults assigned male sex at birth who reported anal sex with men in Abuja and Lagos, Nigeria. Participants were tested for STIs and completed questionnaires about sexual behaviours and social stigma every 3 months. Participants were categorized as cis‐MSM, TGW or non‐binary/other based on self‐reported gender identity. Gender group comparisons were made of HIV, gonorrhoea and chlamydia prevalence and incidence; stigma indicators; and condom use during anal sex.

Results

Among 2795 participants, there were 2260 (80.8%) cis‐MSM, 284 (10.2%) TGW and 251 (9.0%) non‐binary/other individuals with median age of 23 years (interquartile range 20–27). HIV prevalence among cis‐MSM, TGW and non‐binary/other participants was 40.8%, 51.5% and 47.6%, respectively (p = 0.002). HIV incidence was 8.7 cases per 100 person‐years (PY) (95% confidence interval [CI] 6.9–10.8), 13.1 cases/100 PY (95% CI 6.5–23.4) and 17.6 cases/100 PY (95% CI 9.8–29.0, p = 0.025), respectively. Anorectal gonorrhoea incidence was lower in cis‐MSM than TGW (22.2 [95% CI 19.6–25.0] vs. 35.9 [95% CI 27.3–46.3]). TGW were more likely than cis‐MSM to report being affected by stigma, including assault (47.2% vs. 32.3%), fear of walking around (32.4% vs. 19.2%) and healthcare avoidance (25.0% vs. 19.1%; all p < 0.05). TGW were more likely to report always using condoms than non‐binary/other individuals (35.3% vs. 26.2%, p = 0.041) during receptive anal sex.

Conclusions

Sexual and gender minorities in Nigeria have heterogeneous sexual behaviours and experiences of social stigma that may influence the vulnerability to HIV and other STIs. There is a need for tailored interventions that acknowledge and are informed by gender. Further research is needed, particularly among understudied non‐binary individuals, to better understand disparities and inform tailored interventions to improve outcomes among these communities.

The Operationalisation of Sex and Gender in Quantitative Health-Related Research: A Scoping Review

Current trends in quantitative health research have highlighted the inadequacy of the usual operationalisation of sex and gender, resulting in a growing demand for more nuanced options. This scoping review provides an overview of recent instruments for the operationalisation of sex and gender in health-related research beyond a concept of mutually exclusive binary categories as male or masculine vs. female or feminine. Our search in three databases (Medline, Scopus and Web of Science) returned 9935 matches, of which 170 were included. From these, we identified 77 different instruments. The number and variety of instruments measuring sex and/or gender in quantitative health-related research increased over time. Most of these instruments were developed with a US-American student population. The majority of instruments focused on the assessment of gender based on a binary understanding, while sex or combinations of sex and gender were less frequently measured. Different populations may require the application of different instruments, and various research questions may ask for different dimensions of sex and gender to be studied. Despite the clear interest in the development of novel sex and/or gender instruments, future research needs to focus on new ways of operationalisation that account for their variability and multiple dimensions.

Cross-sectional assessment of determinants of STIs among men who have sex with men and transgender women in Kigali, Rwanda

BACKGROUND

STIs among men who have sex with men (MSM) and transgender women (TGW) continue to increase. In Rwanda, STI management relies on syndromic management with limited empirical data characterising the burden of specific STIs among MSM/TGW. This study evaluated the prevalence of syphilis, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and associated factors among MSM/TGW in Kigali.

METHODS

From March to August 2018, 737 MSM/TGW >18 years were enrolled using respondent-driven sampling (RDS). Structured interviews and HIV/STI screening were conducted. Syphilis was screened with rapid plasma reagin confirmed by Treponema pallidum hemagglutination assay. CT/NG were tested by Cepheid GeneXpert. RDS-adjusted multivariable Poisson regression models with robust variance estimation were used to evaluate factors associated with any STI, and determinants of urethral and rectal STIs separately.

RESULTS

Prevalence of any STI was 20% (RDS adjusted: 16.7% (95% CI: 13.2% to 20.2%)). Syphilis was 5.7% (RDS adjusted: 6.8% (95% CI: 4.3% to 9.4%)). CT was 9.1% (RDS adjusted: 6.1% (95% CI: 3.9% to 8.4%)) and NG was 8.8% (RDS adjusted: 7.1% (95% CI: 4.9% to 9.2%)). STIs were more common among older MSM and those with HIV (p<0.05). Of CT infections, 67% were urethral, 27% rectal and 6% were dual site. For NG infections, 52% were rectal, 29% urethral and 19% were dual site. Overall, 25.8% (23 of 89) of those with confirmed STI and returned for their results were symptomatic at time of testing.STI symptoms in the previous year (adjusted prevalence ratio (aPR): 1.94 (95% CI: 1.26 to 2.98)) were positively associated with any STI. Being circumcised was negatively associated with any STI (aPR: 0.47 (95% CI: 0.31 to 0.73)). HIV was positively associated with rectal STIs (aPR: 3.50 (95% CI: 1.09 to 11.21)) but negatively associated with urethral STIs.

CONCLUSION

MSM/TGW, especially those living with HIV, are at high risk of STIs in Rwanda with the vast majority being asymptomatic. These data suggest the potential utility of active STI surveillance strategies using highly sensitive laboratory methods among those at high risk given the anatomical distribution and limited symptomatology of STIs observed among Rwandan MSM/TGW.

Alcohol and cannabis use during the COVID-19 pandemic among transgender, gender-diverse, and cisgender adults in Canada

BACKGROUND

This study examined whether heavy episodic drinking (HED), cannabis use, and subjective changes in alcohol and cannabis use during the COVID-19 pandemic differ between transgender and gender-diverse (TGD) and cisgender adults.

METHODS

Successive waves of web-based cross-sectional surveys.

SETTING

Canada, May 2020 to March 2021.

PARTICIPANTS

6,016 adults (39 TGD, 2,980 cisgender men, 2,984 cisgender women, and 13 preferred not to answer), aged ≥18 years.

MEASUREMENTS

Measures included self-reported HED (≥5 drinks on one or more occasions in the previous week for TGD and cisgender men and ≥4 for cisgender women) and any cannabis use in the previous week. Subjective changes in alcohol and cannabis use in the past week compared to before the pandemic were measured on a five-point Likert scale (1: much less to 5: much more). Binary and ordinal logistic regressions quantified differences between TGD and cisgender participants in alcohol and cannabis use, controlling for age, ethnoracial background, marital status, education, geographic location, and living arrangement.

RESULTS

Compared to cisgender participants, TGD participants were more likely to use cannabis (adjusted odds ratio (aOR)=3.78, 95%CI: 1.89, 7.53) and to have reported subjective increases in alcohol (adjusted proportional odds ratios (aPOR)= 2.00, 95%CI: 1.01, 3.95) and cannabis use (aPOR=4.56, 95%CI: 2.13, 9.78) relative to before the pandemic. Compared to cisgender women, TGD participants were more likely to use cannabis (aOR=4.43, 95%CI: 2.21, 8.87) and increase their consumption of alcohol (aPOR=2.05, 95%CI: 1.03, 4.05) and cannabis (aPOR=4.71, 95%CI: 2.18, 10.13). Compared to cisgender men, TGD participants were more likely to use cannabis (aOR=3.20, 95%CI: 1.60, 6.41) and increase their use of cannabis (aPOR=4.40, 95%CI: 2.04, 9.49). There were no significant differences in HED between TGD and cisgender participants and in subjective change in alcohol between TGD and cisgender men; however, the odds ratios were greater than one as expected.

CONCLUSIONS

Increased alcohol and cannabis use among TGD populations compared to before the pandemic may lead to increased health disparities. Accordingly, programs targeting the specific needs of TGD individuals should be prioritized.

Promoting a gender-affirming environment in research: implications for research nurses

Background: Approximately 25 million people around the world identify as transgender, and the numbers are growing. While visibility of transgender communities has increased, significant healthcare disparities remain. Transgender individuals report being less inclined to share their sex assigned at birth due to fear of stigmatization and mistrust of the medical community. The mistrust and inequity experienced by transgender individuals are not limited to clinical care and may extend to clinical research as well. Aim and method: The aim of this paper is to start a conversation about barriers to participating in research and the role of research staff, specifically the Clinical Research Nurse, in promoting engagement of transgender individuals in clinical research trials. Discussion and conclusions: A discussion of safety considerations, data integrity, and implications for data management is included. Because disparities may result in large part from lack of education and knowledge on best practices for providing care for this population, recommendations for fostering a culture of competence and gender-affirming care among research professionals featuring the role of the research nurse will be discussed.

HIV transmission patterns among transgender women, their cisgender male partners, and cisgender MSM in Lima, Peru: A molecular epidemiologic and phylodynamic analysis

BACKGROUND

Transgender women (TW) in Peru are disproportionately affected by HIV. The role that cisgender men who have sex with TW (MSTW) and their sexual networks play in TW's risk of acquiring HIV is not well understood. We used HIV sequences from TW, MSTW, and cisgender men who have sex with men (MSM) to examine transmission dynamics between these groups.

METHODS

We used HIV-1 pol sequences and epidemiologic data collected through three Lima-based studies from 2013 to 2018 (n = 139 TW, n = 25 MSTW, n = 303 MSM). We identified molecular clusters based on pairwise genetic distance and used structured coalescent phylodynamic modeling to estimate transmission patterns between groups.

FINDINGS

Among 200 participants (43%) found in 62 clusters, the probability of clustering did not differ by group. Both MSM and TW were more likely to cluster with members of their own group than would be expected based on random mixing. Phylodynamic modeling estimated that there was frequent transmission from MSTW to TW (67·9% of transmission from MSTW; 95%CI = 52·8-83·2%) and from TW to MSTW (76·5% of transmissions from TW; 95%CI = 65·5-90·3%). HIV transmission between MSM and TW was estimated to comprise a small proportion of overall transmissions (4·9% of transmissions from MSM, and 11·8% of transmissions from TW), as were transmissions between MSM and MSTW (7·2% of transmissions from MSM, and 32·0% of transmissions from MSTW).

INTERPRETATION

These results provide quantitative evidence that MSTW play an important role in TW's HIV vulnerability and that MSTW have an HIV transmission network that is largely distinct from MSM.

Sampling bias in Brazilian studies on transgender and gender diverse populations: the two-step measure for assessing gender identity in surveys

Abstract: Correctly recognizing gender identity in population-based surveys is essential to develop effective public health strategies to improve the living conditions of transgender and gender-diverse populations, as well as to adequately collect data on cisgender individuals. This study aims to present the two-step measure as the best strategy for assessing gender identity in Brazilian surveys, thus we performed two separate analyses. Firstly, we conducted a systematic review concerning HIV-related care among Brazilian transgender and gender-diverse populations to assess the strategy used to identify participants’ gender identity. Secondly, we re-analyzed data from a recent survey that included Brazilian transgender populations, comparing characteristics and health outcomes from the sample identified by single-item and by the two-step measure. Concerning the systematic review, from 6,585 references, Brazilian research teams published seven articles, and only one study used the two-step measure. Regarding this survey, the two-step measure recognized 567 cisgender and 773 transgender and gender diverse participants among the 1,340 participants who answered the questionnaire, whereas the single-item measure was able to recognize only 540 transgender and gender diverse people. Furthermore, 31 transgender women self-identified as “transgender men” on the single-item measure. Therefore, although scarcely used in Brazil, the two-step measure is a more accurate strategy to recognize gender identity.

Associations between school-related factors and mental health among transgender and gender diverse youth

Transgender and gender diverse youth (TGD) report high rates of mental health concerns. However, there is reason to expect that among TGD youth there is variation in mental health experiences related to specific aspects of gender identity. Furthermore, although certain school characteristics are related to improved mental health for sexual minority youth, it is unclear whether the same school characteristics are associated with improved mental health for TGD youth and whether gender identity moderates the associations between school characteristics and mental health. Using baseline data from Project AVANT, a longitudinal study of TGD youth ages 14-18 years in the United States (N = 252), we report on several mental health outcomes (i.e., depression, anxiety, nonsuicidal self-injury, and PTSD), with attention to differences by gender identity. Secondly, we examined associations of three protective school-related factors (i.e., school-connectedness, presence of a Gay-Straight or Gender-Sexuality Alliance [GSA], and state mandated protections for sexual and gender minority students) with TGD youth mental health. TGD youth reported elevated levels of anxious and depressive symptoms, with nonbinary youth assigned female at birth reporting higher mean depressive symptoms relative to transgender females. Among the aggregate sample of TGD youth, 69.9% reported clinically significant anxiety, 57.9% reported clinically significant depression, 56.7% reported nonsuicidal self-injury, and 46.4% met screening criteria for posttraumatic stress disorder. Despite a small effect size, greater school-connectedness was significantly associated with fewer mental health concerns and gender identity moderated the association between school-connectedness and number of anxiety symptoms. Gender identity also moderated the association between presence of a GSA and number of anxious symptoms, depressive symptoms, and clinically significant depression, respectively. No significant associations of state-level protections and mental health outcomes were detected. Findings highlight the importance of improving mental health and fostering GSA-engagement and school-connectedness among TGD youth. Implications for school psychologists are discussed.

Health and Health Care Among Transgender Adults in the United States

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Co-occurring substance use and psychological distress among exclusive e-cigarette use and other tobacco use among sexual and gender minorities in Texas

BACKGROUND

There is a dearth of literature on sexual and gender minority (SGM) only data that examines the association between tobacco use, co-occurring substance use, and psychological distress.

METHODS

Using SGM-only primary data collected between March 2016 and January 2017, participants were categorized based on recent tobacco use and prevalence estimates were calculated for exclusive e-cigarette use and use of other tobacco products. The strength of the association between tobacco use, recent hazardous alcohol use, illicit substance use, and having a diagnosis for depression, anxiety, or PTSD was estimated. Bivariate and adjusted multinomial logistic regression analyses were used to obtain estimates.

RESULTS

A third of participants (32.91%) reported recent tobacco use. Of these, 8.79% were exclusive e-cigarette users and 24.12% used other tobacco products. Compared to non-tobacco users, e-cigarette users were more likely to have recently used illicit drugs (RRR= 3.00 [1.89, 4.77]) and participated in a substance use treatment program (RRR= 7.98 [1.76, 36.15]). Participants categorized as using other tobacco products, when compared to non-tobacco users, were more likely to have recently used illicit drugs (RRR= 2.05 [1.46, 2.86]), engaged in hazardous drinking (RRR= 2.27 [1.63, 3.16]), and participated in a substance use treatment program (RRR= 9.53 [3.14, 28,88]). They were also more likely to have been recently diagnosed with PTSD (RRR= 3.40 [1.82, 6.34]).

CONCLUSIONS

SGM tobacco users are more likely to engage in hazardous drinking and illicit substance use and access substance use treatment services. There is an opportunity to reduce tobacco use among SGM individuals by developing, implementing, and evaluating tailored tobacco cessation interventions within substance use treatment facilities.

Transgender-specific COVID-19-related stressors and their association with depressive symptoms among transgender adults: A nationwide cross-sectional survey in South Korea

Introduction

COVID-19 has disproportionately impacted marginalized groups, including transgender populations, reproducing and exacerbating inequalities and vulnerabilities that existed in those groups prior to the pandemic. This study aimed to assess the prevalence of transgender-specific COVID-19-related stressors and their association with depressive symptoms among South Korean transgender adults.

Methods

We conducted a nationwide cross-sectional study of 564 South Korean transgender adults (trans women, trans men, and nonbinary people) from October 7 to October 31, 2020. We measured four transgender-specific COVID-19-related stressors as follows: (A) had difficulty receiving gender-affirming healthcare due to economic hardship related to COVID-19, (B) had difficulty receiving gender-affirming healthcare due to limited access to hospitals under the COVID-19 situation, (C) had difficulty purchasing a public face mask due to gender information on an identification card, and (D) avoided getting a COVID-19 test in fear of unfair treatment and dirty looks due to gender identity, despite having COVID-19 symptoms. Past-week depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale.

Results

Of the total participants, 30.7% experienced any of the four transgender-specific COVID-19-related stressors, and 70.2% were classified as having depressive symptoms during the past week. We found statistically significant associations with depressive symptoms among participants who reported that they had difficulty receiving gender-affirming healthcare due to either economic hardship (adjusted prevalence ratio [aPR] = 1.20, 95% Confidence Interval [CI] = 1.05-1.37) or limited access to hospitals (aPR = 1.15, 95% CI = 1.00-1.32), respectively. Furthermore, those who had two or more of the four transgender-specific COVID-19-related stressors were 1.21 times (95% CI = 1.05-1.40) more likely to report depressive symptoms, compared to those who did not report any stressor.

Conclusion

Transgender-specific COVID-19-related stressors may negatively influence depressive symptoms among South Korean transgender adults. Given these findings, transgender-inclusive interventions should be implemented at the policy level during the COVID-19 pandemic in South Korea.

Identification of Transgender People With Cancer in Electronic Health Records: Recommendations Based on CancerLinQ Observations

PURPOSE

Cancer prevalence and outcomes data, necessary to understand disparities in transgender populations, are significantly hampered because gender identity data are not routinely collected. A database of clinical data on people with cancer, CancerLinQ, is operated by the ASCO and collected from practices across the United States and multiple electronic health records.

METHODS

To attempt to identify transgender people with cancer within CancerLinQ, we used three criteria: (1) International Classification of Diseases 9/10 diagnosis (Dx) code suggestive of transgender identity; (2) male gender and Dx of cervical, endometrial, ovarian, fallopian tube, or other related cancer; and (3) female gender and Dx of prostate, testicular, penile, or other related cancer. Charts were abstracted to confirm transgender identity.

RESULTS

Five hundred fifty-seven cases matched inclusion criteria and two hundred and forty-two were abstracted. Seventy-six percent of patients with Dx codes suggestive of transgender identity were transgender. Only 2% and 3% of the people identified by criteria 2 and 3 had evidence of transgender identity, respectively. Extrapolating to nonabstracted data, we would expect to identify an additional four individuals in category 2 and an additional three individuals in category 3, or a total of 44. The total population in CancerLinQ is approximately 1,300,000. Thus, our methods could identify 0.003% of the total population as transgender.

CONCLUSION

Given the need for data regarding transgender people with cancer and the deficiencies of current data resources, a national concerted effort is needed to prospectively collect gender identity data. These efforts will require systemic efforts to create safe healthcare environments for transgender people.

Challenging the binary: Gender/sex and the bio-logics of normalcy

BACKGROUND

We are witnessing renewed debates regarding definitions and boundaries of human gender/sex, where lines of genetics, gonadal hormones, and secondary sex characteristics are drawn to defend strict binary categorizations, with attendant implications for the acceptability and limits of gender identity and diversity.

AIMS

Many argue for the need to recognize the entanglement of gender/sex in humans and the myriad ways that gender experience becomes biology; translating this theory into practice in human biology research is essential. Biological anthropology is well poised to contribute to these societal conversations and debates. To do this effectively, a reconsideration of our own conceptions of gender/sex, gender identity, and sexuality is necessary.

METHODS

In this article, we discuss biological variation associated with gender/sex and propose ways forward to ensure we are engaging with gender/sex diversity. We base our analysis in the concept of "biological normalcy," which allows consideration of the relationships between statistical distributions and normative views. We address the problematic reliance on binary categories, the utilization of group means to represent typical biologies, and document ways in which binary norms reinforce stigma and inequality regarding gender/sex, gender identity, and sexuality.

DISCUSSION AND CONCLUSIONS

We conclude with guidelines and methodological suggestions for how to engage gender/sex and gender identity in research. Our goal is to contribute a framework that all human biologists can use, not just those who work with gender or sexually diverse populations. We hope that in bringing this perspective to bear in human biology, that novel ideas and applications will emerge from within our own discipline.

Gender minoritized students and academic engagement in Brazilian adolescents: Risk and protective factors

Gender minoritized students experience unique challenges in their school environments that may have consequences for their educational outcomes, including academic engagement. The goal of the current study was to understand the association between gender identity and academic engagement among adolescents attending public high schools in Paraná, Brazil (N = 10,828). In particular, student perceptions of student-teacher relationships, school rule fairness and clarity, school-wide academic engagement, and peer victimization were examined as four facilitator/barrier factors that may account for lower levels of academic engagement for gender minoritized students as compared to their cisgender peers, and these processes were tested for differences across race/ethnicity. Public high school students (ages 12-18 years) completed an in-class survey assessing their gender identities, perceptions of the school environment, and academic engagement. Gender minoritized students reported significantly lower levels of academic engagement as compared to their cisgender peers. They also reported less clear and fair school rules, lower levels of school-wide academic engagement, and higher levels of victimization. These facilitator/barrier variables partially accounted for the lower levels of academic engagement reported by gender minoritized students. No significant differences were observed for gender identity according to race/ethnicity. These findings suggest that facilitators/barriers that account for academic engagement for students in general partially explain gender identity-related disparities, and the implications for school psychologists are discussed.

Influence of Stress, Gender, and Minority Status on Cardiovascular Disease Risk in the Hispanic/Latino Community: Protocol for a Longitudinal Observational Cohort Study

BACKGROUND

Hispanic/Latino sexual and gender minorities (SGM) are the fastest growing ethnic group of SGM in the United States. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among Hispanics/Latinos. SGM inequities in CVD risk have been identified as early as young adulthood, and minority stress has been identified as a potential mediator. Yet, the small number of ethnic or racial minority participants in SGM studies have precluded the examination of the intersections of sexual orientation, gender identity, and race and ethnicity.

OBJECTIVE

Minority stress models conceptualize relationships between stressors in minority groups and health outcomes. In this study, we will (1) examine the influence of sexual orientation and gender identity on CVD risk among all Hispanic Community Health Study/Study of Latinos (HCHS/SOL) participants at visit 3 (2021-2024; N~9300); (2) model pathways from sexual orientation and gender identity to CVD risk through stigma, discrimination, and stress in a 1:2 matched subcohort of SGM and non-SGM participants at visit 3 (n~1680); and (3) examine the influence of resilience factors on sexual orientation or gender identity and CVD risk relationships among subcohort participants at visit 3 (n~1680).

METHODS

This study will leverage existing data from the parent HCHS/SOL study (collected since 2008) while collecting new data on sexual orientation, gender identity, stigma, discrimination, stress, coping, social support, and CVD risk. Data analysis will follow the SGM minority stress model, which states that excess stigma against SGM populations leads to minority stress that increases CVD risk. In this model, coping and social support serve as resilience factors that can mitigate the impact of minority stress on CVD risk. Cross-sectional and longitudinal regression models as well as structural equation models will be used to test these relationships.

RESULTS

This study was funded by the National Heart, Lung, and Blood Institute in March 2020. Recruitment is scheduled to begin in the first quarter of 2021 and continue through 2024.

CONCLUSIONS

Understanding the influence of stigma-induced stress on CVD risk among Hispanic/Latino SGM has significant implications for the development of culturally specific CVD risk reduction strategies. Study findings will be used to build on identified Hispanic/Latino cultural strengths to inform adaptation and testing of family and community acceptance interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/28997.

Opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment needs of transgender and gender diverse adults

BACKGROUND

Limited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults.

METHODS

In 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs.

RESULTS

Overall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values<0.05). Younger age, stigma in healthcare, and misusing opioid pain medications were associated with increased odds of unmet BHTx needs; post-traumatic stress disorder and family support were associated with decreased odds of unmet BHtx needs (p-values<0.05).

CONCLUSIONS

Addressing disparities in opioid pain medication misuse among TGD people requires systematic improvements in healthcare access, including efforts to create TGD-inclusive BHtx environments with providers who are equipped to recognize and treat the social and structural drivers of TGD health inequities, including opioid pain medication misuse.

healthcareCOVID: a national cross-sectional observational study identifying risk factors for developing suspected or confirmed COVID-19 in UK healthcare workers

Objective

To establish the prevalence, risk factors and implications of suspected or confirmed coronavirus disease 2019 (COVID-19) infection among healthcare workers in the United Kingdom (UK).

Design

Cross-sectional observational study.

Setting

UK-based primary and secondary care.

Participants

Healthcare workers aged ≥18 years working between 1 February and 25 May 2020.

Main outcome measures

A composite endpoint of laboratory-confirmed diagnosis of SARS-CoV-2, or self-isolation or hospitalisation due to suspected or confirmed COVID-19.

Results

Of 6,152 eligible responses, the composite endpoint was present in 1,806 (29.4%) healthcare workers, of whom 49 (0.8%) were hospitalised, 459 (7.5%) tested positive for SARS-CoV-2, and 1,776 (28.9%) reported self-isolation. Overall, between 11,870 and 21,158 days of self-isolation were required by the cohort, equalling approximately 71 to 127 working days lost per 1,000 working days. The strongest risk factor associated with the presence of the primary composite endpoint was increasing frequency of contact with suspected or confirmed COVID-19 cases without adequate personal protective equipment (PPE): 'Never' (reference), 'Rarely' (adjusted odds ratio 1.06, (95% confidence interval: [0.87-1.29])), 'Sometimes' (1.7 [1.37-2.10]), 'Often' (1.84 [1.28-2.63]), 'Always' (2.93, [1.75-5.06]). Additionally, several comorbidities (cancer, respiratory disease, and obesity); working in a 'doctors' role; using public transportation for work; regular contact with suspected or confirmed COVID-19 patients; and lack of PPE were also associated with the presence of the primary endpoint. A total of 1,382 (22.5%) healthcare workers reported lacking access to PPE items while having clinical contact with suspected or confirmed COVID-19 cases.

Conclusions

Suspected or confirmed COVID-19 was more common in healthcare workers than in the general population and is associated with significant workforce implications. Risk factors included inadequate PPE, which was reported by nearly a quarter of healthcare workers. Governments and policymakers must ensure adequate PPE is available as well as developing strategies to mitigate risk for high-risk healthcare workers during future COVID-19 waves.

Mental Health Challenges and Needs among Sexual and Gender Minority People in Western Kenya

Background: Sexual and gender minority (SGM) people in Kenya face pervasive socio-cultural and structural discrimination. Persistent stress stemming from anti-SGM stigma and prejudice may place SGM individuals at increased risk for negative mental health outcomes. This study explored experiences with violence (intimate partner violence and SGM-based violence), mental health outcomes (psychological distress, PTSD symptoms, and depressive symptoms), alcohol and other substance use, and prioritization of community needs among SGM adults in Western Kenya. Methods: This study was conducted by members of a collaborative research partnership between a U.S. academic institution and a Kenyan LGBTQ civil society organization (CSO). A convenience sample of 527 SGM adults (92.7% ages 18-34) was recruited from community venues to complete a cross-sectional survey either on paper or through an online secure platform. Results: For comparative analytic purposes, three sexual orientation and gender identity (SOGI) groups were created: (1) cisgender sexual minority women (SMW; 24.9%), (2) cisgender sexual minority men (SMM; 63.8%), and (3) gender minority individuals (GMI; 11.4%). Overall, 11.7% of participants reported clinically significant levels of psychological distress, 53.2% reported clinically significant levels of post-traumatic stress disorder (PTSD) symptoms, and 26.1% reported clinically significant levels of depressive symptoms. No statistically significant differences in clinical levels of these mental health concerns were detected across SOGI groups. Overall, 76.2% of participants reported ever using alcohol, 45.6% home brew, 43.5% tobacco, 39.1% marijuana, and 27.7% miraa or khat. Statistically significant SOGI group differences on potentially problematic substance use revealed that GMI participants were less likely to use alcohol and tobacco daily; and SMM participants were more likely to use marijuana daily. Lifetime intimate partner violence (IPV) was reported by 42.5% of participants, and lifetime SGM-based violence (SGMV) was reported by 43.4%. GMI participants were more likely than other SOGI groups to have experienced both IPV and SGMV. Participants who experienced SGMV had significantly higher rates of clinically significant depressive and PTSD symptoms. Conclusions: Despite current resilience demonstrated by SGM adults in Kenya, there is an urgent need to develop and deliver culturally appropriate mental health services for this population. Given the pervasiveness of anti-SGM violence, services should be provided using trauma-informed principles, and be sensitive to the lived experiences of SGM adults in Kenya. Community and policy levels interventions are needed to decrease SGM-based stigma and violence, increase SGM visibility and acceptance, and create safe and affirming venues for mental health care. Political prioritization of SGM mental health is needed for sustainable change.

Biocultural approaches to transgender and gender diverse experience and health: Integrating biomarkers and advancing gender/sex research

Transgender and gender diverse (TGD) people are increasingly visible in U.S. communities and in national media. With this increased visibility, access to gender affirming healthcare is also on the rise, particularly for urban youth. Political backlash and entrenchment in a gender binary, however, continue to marginalize TGD people, increasing risk for health disparities. The 2016 National Institute of Health recognition of sexual and gender minority people as a health disparities population increases available funding for much-needed research. In this article, we speak to the need for a biocultural human biology of gender/sex diversity by delineating factors that influence physiological functioning, mental health, and physical health of TGD people. We propose that many of these factors can best be investigated with minimally invasively collected biomarker samples (MICBS) and discuss how to integrate MICBS into research inclusive of TGD people. Research use of MICBS among TGD people remains limited, and wider use could enable essential biological and health data to be collected from a population often excluded from research. We provide a broad overview of terminology and current literature, point to key research questions, and address potential challenges researchers might face when aiming to integrate MCIBS in research inclusive of transgender and gender diverse people. We argue that, when used effectively, MICBS can enhance human biologists' ability to empirically measure physiology and health-related outcomes and enable more accurate identification of pathways linking human experience, embodiment, and health.

A cross-sectional gender-sensitive analysis of depressive symptoms in patients with advanced cancer

BACKGROUND

Patients with advanced cancer commonly report depressive symptoms. Examinations of gender differences in depressive symptoms in patients with advanced cancer have yielded inconsistent findings.

AIM

The objective of this study was to investigate whether the severity and correlates of depressive symptoms differ by gender in patients with advanced cancer.

DESIGN

Participants completed measures assessing sociodemographic and medical characteristics, disease burden, and psychosocial factors. Depressive symptoms were examined using the Patient Health Questionnaire, and other measures included physical functioning, symptom burden, general anxiety, death related distress, and dimensions of demoralization. A cross-sectional analysis examined the univariate and multivariate relationships between gender and depressive symptoms, while controlling for important covariates in multivariate analyses.

SETTING/PARTICIPANTS

Patients with advanced cancer (N = 305, 40% males and 60% females) were recruited for a psychotherapy trial from outpatient oncology clinics at a comprehensive cancer center in Canada.

RESULTS

Severity of depressive symptoms was similar for males (M = 7.09, SD = 4.59) and females (M = 7.66, SD = 5.01), t(303) = 1.01, p = 0.314. Greater general anxiety and number of cancer symptoms were associated with depressive symptoms in both males and females. Feeling like a failure (β = 0.192), less death anxiety (β = -0.188), severity of cancer symptoms (β = 0.166), and older age (β = 0.161) were associated with depressive symptoms only in males, while disheartenment (β = 0.216) and worse physical functioning (β = 0.275), were associated with depressive symptoms only in females.

CONCLUSIONS

Males and females report similar levels of depressive symptoms but the pathways to depression may differ by gender. These differences suggest the potential for gender-based preventive and therapeutic interventions in this population.

Negative Transgender-Related Media Messages Are Associated with Adverse Mental Health Outcomes in a Multistate Study of Transgender Adults

Purpose: The purpose of this study was to examine the extent to which transgender people have observed negative transgender-related messages in the media and the relationship between negative media message exposure and the mental health of transgender people. Methods: In 2019, 545 transgender adults completed an online survey assessing demographics, negative transgender-related media messages, violence, and mental health. Separate multivariable logistic regression models examined the association of frequency of negative media exposure and clinically significant symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and global psychological distress. Results: Mean age of the sample was 31.2 years (standard deviation [SD] = 11.2). Nearly half identified as nonbinary (42.2%), 82.0% were White, non-Hispanic, 56.9% had a college degree, and 67.0% were financially insecure. The majority reported experiencing childhood abuse (60.6%) and abuse in adulthood (58.0%). The mean frequency of exposure to negative transgender-related media was 6.41 (SD = 2.9) with 97.6% of the sample reporting exposure to negative media depictions of transgender people across a range of mediums. In separate multivariable models adjusted for age, gender identity, race, education, income, and childhood/adult abuse, more frequent exposure to negative depictions of transgender people in the media was significantly associated with clinically significant symptoms of depression (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] = 1.08-1.29; p = 0.0003); anxiety (aOR = 1.26; 95% CI = 1.14-1.40; p < 0.0001); PTSD (aOR = 1.25; 95% CI = 1.16-1.34; p < 0.0001); and global psychological distress (aOR = 1.28; 95% CI = 1.15-1.42; p < 0.0001). Conclusion: Exposure to negative media messages from multiple sources necessitates multilevel interventions to improve the mental health of transgender people and curb stigma at its source.

The feasibility of recruiting and retaining men who have sex with men and transgender women in a multinational prospective HIV prevention research cohort study in sub-Saharan Africa (HPTN 075)

INTRODUCTION

Men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa (SSA) are profoundly affected by HIV with high HIV prevalence and incidence. This population also faces strong social stigma and legal barriers, potentially impeding participation in research. To date, few multi-country longitudinal HIV research studies with MSM/TGW have been conducted in SSA. Primary objective of the HIV Prevention Trials Network (HPTN) 075 study was to assess feasibility of recruiting and retaining a multinational prospective cohort of MSM/TGW in SSA for HIV prevention research.

METHODS

HPTN 075, conducted from 2015 to 2017, was designed to enroll 400 MSM/TGW at four sites in SSA (100 per site: Kisumu, Kenya; Blantyre, Malawi; Cape Town, South Africa; and Soweto, South Africa). The number of HIV-positive persons was capped at 20 per site; HIV-positive persons already in care were excluded from participation. The one-year study included five biobehavioural assessments. Community-based input and risk mitigation protocols were included in study design and conduct.

RESULTS

Of 624 persons screened, 401 were enrolled. One in five participants was classified as transgender. Main reasons for ineligibility included: (a) being HIV positive after the cap was reached (29.6%); (b) not reporting anal intercourse with a man in the preceding three months (20.6%); and (c) being HIV positive and already in care (17.5%). Five (1.2%) participants died during the study (unrelated to study participation). 92.9% of the eligible participants (368/396) completed the final study visit and 86.1% participated in all visits. The main, overlapping reasons for early termination included being (a) unable to adhere to the visit schedule, predominantly because of relocation (46.4%), and (b) unable to contact the participant (32.1%). Participants reported strong motivation to participate and few participation barriers. Four participants reported social harms (loss of confidentiality and sexual harassment by study staff) that were successfully addressed.

CONCLUSIONS

HPTN 075 successfully enrolled a multinational sample of MSM/TGW in SSA in a prospective HIV prevention research study with a high retention rate and few documented social harms. This supports the feasibility of conducting large-scale research trials in this population to address its urgent, unmet HIV prevention needs.

Identifying Health Differences Between Transgender and Cisgender Gay, Bisexual and Other Men Who Have Sex With Men Using a Community-Based Approach

In this article, we describe a community-based research (CBR) approach to making a national online survey of gay, bisexual, and other men who have sex with men (GBMSM) inclusive of transgender GBMSM by working with members of the transgender community at all stages of the research process. This collaboration resulted in 209 transgender GBMSM completing our survey and we contrasted their health experiences with 7439 cisgender GBMSM. We found that transgender GBMSM were less likely than cisgender GBMSM to report intercourse without a condom (AOR 0.43; 95% CI: 0.28-0.66) and to have had an HIV test (AOR 0.64; 95% CI 0.49-0.85). Transgender GBMSM were more likely to report discrimination in the health care system in their lifetime (AOR 4.17; 95% CI 3.03-5.73), to self-rate their health as poor (AOR 3.47; 95% CI 2.52-4.80), and to have discussed depression (AOR 3.47; 95% CI 262-4.59) or anxiety (AOR 3.27; 95% CI 2.47-4.33) with a health care provider. Our experience highlights the feasibility of including transgender individuals in GBMSM research, while the results affirm the need for GBMSM health services to take into account the unique experiences of transgender GBMSM.

What Sexual and Gender Minority People Want Researchers to Know About Sexual Orientation and Gender Identity Questions: A Qualitative Study

Sexual and gender minority (SGM) people-including members of the lesbian, gay, bisexual, transgender, and queer communities-are understudied and underrepresented in research. Current sexual orientation and gender identity (SOGI) questions do not sufficiently engage SGM people, and there is a critical gap in understanding how SOGI questions reduce inclusion and accurate empirical representation. We conducted a qualitative study to answer the question, "For SGM people, what are the major limitations with current SOGI questions?" Focus groups probed reactions to SOGI questions adapted from prior national surveys and clinical best practice guidelines. Questions were refined and presented in semi-structured cognitive interviews. Template analysis using a priori themes guided analysis. There were 74 participants: 55 in nine focus groups and 19 in cognitive interviews. Participants were diverse: 51.3% identified as gender minorities, 87.8% as sexual minorities, 8.1% as Hispanic/Latinx, 13.5% as Black or African-American, and 43.2% as Non-white. Two major themes emerged: (1) SOGI questions did not allow for identity fluidity and complexity, reducing inclusion and representation, and (2) SOGI question stems and answer choices were often not clear as to which SOGI dimension was being assessed. To our knowledge, this represents the largest body of qualitative data studying SGM perspectives when responding to SOGI questions. We present recommendations for future development and use of SOGI measures. Attention to these topics may improve meaningful participation of SGM people in research and implementation of such research within and for SGM communities.

Changes in Sexual and Gender Identity and Their Associations with Internalized Homophobia Among Black Men Who Have Sex with Men in the HPTN 061 BROTHERS Cohort

Sexual and gender identity have frequently been assessed in public health research as static states. However, a substantial and growing body of evidence indicates that both identities may have greater potential for change over time than once supposed. Despite this evidence, research into adult identity change remains relatively limited. Using longitudinal data from 1553 Black men who have sex with men (BMSM) aged 18-68 years and recruited from study locations in six major cities across the country, we examined changes in sexual and gender identities over a period of 12 months. The results showed that sexual and gender identity did indeed change among adult BMSM. Additionally, we explored internalized homophobia (IH) as a potential driver of identity change and found that IH significantly impacts the degree and direction of change, with individuals who reported higher baseline IH more likely to demonstrate a shift toward a heterosexual/straight identity at 6 and 12 months. The results are discussed in light of what is known and unknown regarding identity change, and potential avenues for future research are explored.