LifeSkills for Men (LS4M): Pilot Evaluation of a Gender-Affirmative HIV and STI Prevention Intervention for Young Adult Transgender Men Who Have Sex with Men

Identifying Effective Strategies for Improving Engagement in HIV Prevention and Care Among Transgender Persons in the United States: A Systematic Review

This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

A qualitative exploration of how to support PrEP adherence among young men who have sex with men

New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.

MyPEEPS Mobile App for HIV Prevention Among Transmasculine Youth: Adaptation Through Community-Based Feedback and Usability Evaluation

BACKGROUND

Transgender men and transmasculine youth are at high risk for acquiring HIV. Growing research on transgender men demonstrates increased HIV risk and burden compared with the general US population. Despite biomedical advancements in HIV prevention, there remains a dearth of evidence-based, sexual health HIV prevention interventions for young transgender men. MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) Mobile is a web-based app that builds on extensive formative community-informed work to develop an evidence-based HIV prevention intervention. Our study team developed and tested the MyPEEPS Mobile intervention for 13- to 18-year-old cisgender young men in a national randomized controlled trial, which demonstrated efficacy to reduce sexual risk in the short term-at 3-month follow-up. Trans men and transmasculine youth resonated with basic HIV educational information and sexual scenarios of the original MyPEEPS app for cisgender men, but recognized the app's lack of transmasculine specificity.

OBJECTIVE

The purpose of this study is to detail the user-centered design methods to adapt, improve the user interface, and enhance the usability of the MyPEEPS Mobile app for young transgender men and transmasculine youth.

METHODS

The MyPEEPS Mobile app for young transgender men was adapted through a user-centered design approach, which included an iterative review of the adapted prototype by expert advisors and a youth advisory board. The app was then evaluated through a rigorous usability evaluation.

RESULTS

MyPEEPS Mobile is among the first mobile health interventions developed to meet the specific needs of young transgender men and transmasculine youth to reduce HIV risk behaviors. While many of the activities in the original MyPEEPS Mobile were rigorously developed and tested, there was a need to adapt our intervention to meet the specific needs and risk factors among young transgender men and transmasculine youth. The findings from this study describe the adaptation of these activities through feedback from a youth advisory board and expert advisors. Following adaptation of the content, the app underwent a rigorous usability assessment through an evaluation with experts in human-computer interaction (n=5) and targeted end users (n=20).

CONCLUSIONS

Usability and adaptation findings demonstrate that the MyPEEPS Mobile app is highly usable and perceived as potentially useful for targeting HIV risk behaviors in young transgender men and transmasculine youth.

Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment

BACKGROUND

The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner.

OBJECTIVE

This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults.

METHODS

A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners.

RESULTS

The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants.

CONCLUSIONS

The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.

Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review

We conducted a scoping review of contextual factors impeding uptake and adherence to pre-exposure prophylaxis in transgender communities as an in-depth analysis of the transgender population within a previously published systematic review. Using a machine learning screening process, title and abstract screening, and full-text review, the initial systematic review identified 353 articles for analysis. These articles were peer-reviewed, implementation-related studies of PrEP in the U.S. published after 2000. Twenty-two articles were identified in this search as transgender related. An additional eleven articles were identified through citations of these twenty-two articles, resulting in thirty-three articles in the current analysis. These thirty-three articles were qualitatively coded in NVivo using adapted constructs from the Consolidated Framework for Implementation Research as individual codes. Codes were thematically assessed. We point to barriers of implementing PrEP, including lack of intentional dissemination efforts and patience assistance, structural factors, including sex work, racism, and access to gender affirming health care, and lack of provider training. Finally, over 60% of articles lumped cisgender men who have sex with men with trans women. Such articles included sub-samples of transgender individuals that were not representative. We point to areas of growth for the field in this regard.

Kinky Sex and Deliberate Partner Negotiations: Case Studies of Canadian Transgender Men Who Have Sex with Men, Their HIV Risks, Safer Sex Practices, and Prevention Needs

Growing research in the last two decades has begun to investigate the HIV risks and sexual health practices of transgender men, especially as a subpopulation of men who have sex with men (MSM) that likely shares certain HIV risks and sexual health practices with cisgender MSM, the sociodemographic group that continues to be at highest risk for HIV in many developed countries since the start of the epidemic. As part of our Community-Based Participatory Research project and larger strengths-based qualitative study that was dedicated to examine multiple factors that promote resilience to HIV utilizing the perspectives and lived experiences of middle-aged and older MSM, the case studies we present in this article feature the distinct insights and experiences of three HIV-negative transgender MSM from Downtown Toronto, Ontario, Canada, who participated in our one-on-one interviews. The three case studies provide not only an enlightening snapshot of some of the specific contexts, HIV risks, safer sex practices, and HIV prevention needs of transgender MSM, but also a unique opportunity to critically reflect on the potential implications of the insights and experiences that were shared by our participants, particularly for adapting and developing current and future HIV services and programs to maximally benefit transgender MSM.

A scoping review of alcohol, tobacco, and other drug use treatment interventions for sexual and gender minority populations

BACKGROUND

Alcohol, tobacco, and other drug use are among the most prevalent and important health disparities affecting sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender) populations. Although numerous government agencies and health experts have called for substance use intervention studies to address these disparities, such studies continue to be relatively rare.

METHOD

We conducted a scoping review of prevention and drug treatment intervention studies for alcohol, tobacco, and other drug use that were conducted with SGM adults. We searched three databases to identify pertinent English-language, peer-reviewed articles published between 1985 and 2019.

RESULTS

Our search yielded 71 articles. The majority focused on sexual minority men and studied individual or group psychotherapies for alcohol, tobacco, or methamphetamine use.

CONCLUSION

Our findings highlight the need for intervention research focused on sexual minority women and gender minority individuals and on cannabis and opioid use. There is also a need for more research that evaluates dyadic, population-level, and medication interventions.

FOREST protocol: a qualitative study exploring health and sexuality of transmasculine individuals in France

INTRODUCTION

While current research on sexuality and health often explores sexual behaviours among heterosexual and gay cisgender individuals, little is known about the sexualities of transgender people, especially transmasculine people. When data are available, sexual health is often reduced to risk exposure, not considering in detail social context and determinants that could contribute to a more comprehensive approach, such as general health, class, race, exposure to violence or social representations. Recognising this gap, identified in both national (French) and international scientific literature, this study aims to explore the sexual health of transmasculine people, employing an intersectional approach and considering both positive and negative health determinants.

METHODS

This 2-year research based in the disciplinary field of social psychology, with a gender perspective, and will apply qualitative methods. We adopt a community-based research approach, integrating one university and one community-based organisation in the coordination of the study. In a triangulation perspective, two rounds of semistructured interviews will be performed with key informants (medical practitioners, community-based support services workers, etc) and with people self-identifying as transmasculine. Focus groups will complement data collection.

ETHICS AND DISSEMINATION

FOREST protocol was approved by the Comité d'Évaluation Éthique (CEEI) de l'Institut National de la Santé Et de la Recherche Médicale (CEEI/International Review Board 00003888). The research adopts the principles of open science, and findings will be published assuring participants' confidentiality. Informative flyers and videos will be elaborated to communicate study findings to participants, stakeholders and the transcommunities at large, and data will be stored in lasting archives.

Structural Interventions for HIV Prevention and Care Among US Men Who Have Sex with Men: A Systematic Review of Evidence, Gaps, and Future Priorities

The preponderance of HIV interventions have been behavioral, targeting individual, dyadic, or group dynamics. However, structural-level interventions are required to decrease HIV transmission and increase engagement in care, especially for men who have sex with men (MSM), particularly Black and Latinx MSM. A systematic literature review was conducted to assess the current state of structural interventions; only two studies detailing structural interventions related to HIV for Black and Latinx MSM in the US were identified. An additional 91 studies which discussed structural-level barriers to optimal HIV outcomes among MSM, yet which did not directly evaluate a structural intervention, were also identified. While this paucity of findings was discouraging, it was not unexpected. Results of the systematic review were used to inform guidelines for the implementation and evaluation of structural interventions to address HIV among MSM in the U.S. These include deploying specific interventions for multiply marginalized individuals, prioritizing the deconstruction of structural stigma, and expanding the capacity of researchers to evaluate “natural” policy-level structural interventions through a standardization of methods for rapid evaluative response, and through universal application of sex, sexual orientation, and gender identity demographic measures.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

The persistent and evolving HIV epidemic in American men who have sex with men

Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortative mixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negative interactions with the health-care system. Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

Pediatric Research and Health Care for Transgender and Gender Diverse Adolescents and Young Adults: Improving (Biopsychosocial) Health Outcomes

Adolescent and young adult (AYA) transgender health care and research have expanded rapidly in the United States and abroad, but the effects of gender-affirming social, hormonal, or surgical care on overall health remain unclear. Gender diverse identities, also termed nonbinary, have often been neglected in favor of (male/female) binary identities, even in the context of transgender health care and research. No high quality studies have assessed how gender-affirming medical care impact health inequities in transgender and gender diverse (TG/GD) adults, much less in AYAs, despite the fact that that TG/GD adults have higher than average morbidity and mortality across a host of health concerns, from human immunodeficiency virus infection to thromboembolism, and that reported depression with suicidal ideation is >10 times higher in TG/GD adults than in the general population. TG/GD youth have related but different needs from TG/GD adults. TG/GD AYA are embedded in family and schools, where stigma may be difficult to escape; mental health during adolescence has areas of increased risk as well as resilience; and the effects of early hormonal and surgical interventions on long-term health are insufficiently studied. Because of this, an inclusive and proactive approach to addressing the needs of TG/GD AYA by pediatric clinicians, researchers, and educators is particularly crucial. This article focuses on what is known and unknown about clinical practice, research, and education related to TG/GD health. We highlight the role of gender affirmation by clinicians as they care and advocate for TG/GD AYAs; the potential challenges of hormonal treatment for peripubertal youth; and short- and long-term effects on physical and reproductive health of medical or surgical interventions. We also discuss how social context influences knowledge gaps and the health-relevant risks faced by TG/GD AYA. The challenges are formidable, but opportunities await: high priority research questions to explore, educational gaps to be filled, and advocacy that needs the voices of pediatricians to promote policies to facilitate positive health outcomes for TG/GD AYA.

A systematic review of stigma in sexual and gender minority health interventions

Stigma against sexual and gender minorities is a major driver of health disparities. Psychological and behavioral interventions that do not address the stigma experienced by sexual and gender minorities may be less efficacious. We conducted a systematic review of existing psychological and behavioral health interventions for sexual and gender minorities to investigate how interventions target sexual and gender minority stigma and consider how stigma could affect intervention efficacy. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Eligible studies were peer reviewed and published in English between January 2003 and July 2019 and reported empirical results of behavioral or psychological interventions implemented among sexual and gender minorities. All interventions addressed stigma. We identified 37 eligible interventions. Most interventions targeted sexual minority men. Interventions were frequently developed or adapted for implementation among sexual and gender minorities and addressed multiple levels and types of stigma. Interventions most frequently targeted proximal stressors, including internalized and anticipated stigma. HIV and mental health were the most commonly targeted health outcomes. A limited number of studies investigated the moderating or mediating effects of stigma on intervention efficacy. The application of an intersectional framework was frequently absent and rarely amounted to addressing sources of stigma beyond sexual and gender minority identities. A growing number of interventions address sexual and gender minority stigma in an effort to prevent deleterious health effects. Future research is needed to assess whether stigma modifies the effectiveness of existing psychological and behavioral interventions among sexual and gender minorities. Further, the application of intersectional frameworks is needed to more comprehensively intervene on multiple, intersecting sources of stigma faced by the diverse sexual and gender minority community.

Enhancing Gender-Affirming Provider Communication to Increase Health Care Access and Utilization Among Transgender Men and Trans-Masculine Non-Binary Individuals

Purpose: This study was designed to enhance health care providers' abilities to engage transgender men and trans-masculine non-binary individuals (TMNBI) in sexual and reproductive health care conversations by identifying preferences for provider communication and terminology related to sexual and reproductive anatomy and associated examinations. Methods: From May to July 2017, we conducted a cross-sectional online survey with a convenience sample of TMNBI (N = 1788) in the United States. We examined participants' provider communication experiences and preferences related to sexual and reproductive anatomy, and preferred terminology for sexual and reproductive anatomy and associated examinations. Communication experiences/preferences and preferred terminology were assessed by gender identity and gender-affirming medical interventions (hormones and/or surgery). Results: Most participants had regular access to health care (81.3%); of those, 83% received care from a provider knowledgeable in transgender health. Only 26.9% of participants reported that a provider had ever asked about preferred language for their genitalia/anatomy. The majority of the sample (77.7%) wanted a provider to ask directly for preferred language and 65% wanted a provider to use medical terminology, rather than slang when talking about their body. Participants provided varied responses for their preferred terminology related to sexual and reproductive anatomy and associated examinations. Conclusions: These data underscore the importance of medical providers asking for and then using TMNBI' preferred language during sexual and reproductive health conversations and examinations, rather than assuming that all TMNBI use the same language. Asking for and using TMNBI' preferred language may improve gender-affirming sexual and reproductive health care and increase patient engagement and retention among these individuals.

High Rates of PrEP Eligibility but Low Rates of PrEP Access Among a National Sample of Transmasculine Individuals

BACKGROUND

Transmasculine individuals have been largely ignored in HIV prevention research, and there is a lack of data regarding this population's eligibility for and utilization of HIV pre-exposure prophylaxis (PrEP).

SETTING

National online survey conducted in the United States.

METHODS

Between May and July 2017, we surveyed 1808 transmasculine individuals (aged 18-60 years; 30% people of color and/or Latinx), asking questions about sexual behavior and receipt of sexual health care, including PrEP. We examined the number of individuals who would meet eligibility criteria for PrEP and then used log-linked Poisson regression with robust variance estimation to examine predictors of PrEP eligibility.

RESULTS

Almost one-quarter of the sample (n = 439; 24.3%) met one or more criterion for PrEP eligibility. PrEP eligibility did not differ by age, race/ethnicity, education, or binary gender identity. PrEP eligibility was lower among heterosexual-identified and higher income participants, and was higher among participants who were in open relationships and reported substance use. Among PrEP-eligible individuals, 64.9% had received an HIV test in the past year, 33.9% had received PrEP information from a provider, and 10.9% (n = 48) had received a PrEP prescription. PrEP-eligible individuals who had received a PrEP prescription were more likely to have a binary gender identity, identify as gay, and be taking testosterone.

CONCLUSIONS

A substantial proportion of transmasculine individuals meet PrEP eligibility criteria, but few are receiving adequate PrEP services. Enhanced efforts should be made by providers, programs, and systems to assess HIV-related risk in transmasculine patients and engage them in comprehensive sexual health care.

Gender identity and sexual orientation development among young adult transgender men sexually active with cisgender men: 'I had completely ignored my sexuality … that's for a different time to figure out'

As awareness of issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. Often these narratives are based on binary constructions about both sexual orientation and gender identity. The lack of diverse, representative cultural narratives has implications for identity development and sexual health. Transgender men who have sex with cisgender men in particular represent an understudied and overlooked population who likely experience unique developmental tasks related to the intersection of socially stigmatised sexual orientation and gender identities. This study explores sexual orientation and gender identity development among a sample of young adult transgender men who have sex with men. In-depth interviews using a modified life history method were conducted with 18 young men. Interview transcripts were coded using open, narrative and focused coding methods. Participants discussed milestones in the development of their sexuality and gender identity that map onto existing models, but also described ways in which these processes overlap and intersect in distinct ways. Findings highlight the need for human development models of sexual orientation and gender identity that integrate multiple identity processes. Implications for future research and practice to increase support for young adult transgender men are discussed.

Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research

RATIONALE

A growing body of transgender (trans) health research has explored the relationship between stigma and health; yet, studies have conceptualized and operationalized anti-trans stigma in multiple ways.

OBJECTIVE

This scoping review aims to critically analyze quantitative measures of anti-trans stigma in the U.S. using a socioecological framework.

METHOD

We organized and appraised measures from 126 included articles according to socioecological level: structural, interpersonal, or individual.

RESULTS

Of the identified articles, 36 measured anti-trans stigma at the structural level (i.e., institutional structures and policies), 102 measured anti-trans at the interpersonal level (i.e., community interactions), and 44 measured anti-trans stigma at the individual level (i.e., internalized or anticipated stigma). Definitions of anti-trans stigma varied substantially across articles. Most measures were adapted from measures developed for other populations (i.e., sexual minorities) and were not previously validated for trans samples.

CONCLUSIONS

Studies analyzing anti-trans stigma should concretely define anti-trans stigma. There is a need to develop measures of anti-trans stigma at all socioecological levels informed by the lived experiences of trans people.

Gender Non-affirmation from Cisgender Male Partners: Development and Validation of a Brief Stigma Scale for HIV Research with Transgender Men Who Have Sex with Men (Trans MSM)

Some transgender men who have sex with men (trans MSM) are vulnerable to HIV infection and face stigma from sexual partners. We evaluated a brief 4-item measure of gender non-affirmation from cisgender male partners. A non-probability sample of American trans MSM (n = 843) reporting past 6-month sexual contact with a cisgender male completed a cross-sectional survey. Psychometric analyses assessed the scale and modeled HIV risk associations. Overall, 78% experienced past 6-month gender non-affirmation from cisgender male partners. The scale demonstrated good reliability (α = 0.78). Convergent validity was supported in associations with psychological distress and anxiety (p < 0.05). Lower frequency of cisgender male partner stigma was associated with increased odds of past 6-month HIV testing and decreased odds of past 6-month condomless receptive sex (all p < 0.01). The gender non-affirmation from cisgender male sexual partners scale found negative associations with protective health behaviors and can be used to better understand the context of trans MSM risk behavior.

High risk and low uptake of pre-exposure prophylaxis to prevent HIV acquisition in a national online sample of transgender men who have sex with men in the United States

INTRODUCTION

Trans masculine people who have sex with cisgender ("cis") men ("trans MSM") may be at-risk for HIV infection when they have cis MSM partners or share needles for hormone or recreational drug injection. Limited data are available characterizing indications and uptake of pre-exposure prophylaxis (PrEP) in trans MSM. The aim of this study was to assess PrEP indication and uptake as a means of primary HIV prevention for adult trans MSM in the U.S.

METHODS

Between November and December 2017, a national convenience sample of trans MSM in the U.S. (n = 857) was recruited using participatory methodologies and completed an online survey of demographics, HIV risk, PrEP, behavioural and psychosocial factors. Self-reported receptive anal sex or frontal/vaginal sex (with or without a condom) with a cis male sex partner in past six months was an eligibility criterion. A multivariable logistic regression procedure was used to model PrEP indications (yes/no) per an interpretation of U.S. Centers of Disease Control and Prevention recommendations among those without HIV (n = 843).

RESULTS

The diverse sample was 4.9% Black; 22.1% Latinx ethnicity; 28.4% non-binary gender identity; 32.6% gay-identified; 82.7% on testosterone. Overall, 84.1% had heard of PrEP. Of these, 33.3% reported lifetime PrEP use (21.8% current and 11.5% past). Based on HIV behavioural risk profiles in the last six months, 55.2% of respondents had indications for PrEP. In a multivariable model, factors associated with PrEP indication included where met sex partners, not having sex exclusively with cismen, higher perceived HIV risk, greater number of partners and high cis male partner stigma (all p < 0.05).

DISCUSSION

The majority of trans MSM in this sample had a PrEP indication. Stigma was associated with risk for HIV acquisition and represents a critical target for HIV biobehavioural prevention interventions for trans MSM, who appear to be underutilizing PrEP.

CONCLUSIONS

Results from this study support the full inclusion of trans MSM in HIV biobehavioural prevention efforts. Public health interventions and programmes are needed to reach trans MSM that attend to general MSM risk factors as well as to vulnerabilities specific to trans MSM, including the context of stigma from cis male sexual partners.

Development of a Novel Tool to Assess Intimate Partner Violence Against Transgender Individuals

Intimate partner violence (IPV) takes on unique dimensions when directed against transgender individuals, with perpetrators leveraging transphobia to assert power and control. Standard IPV measurement tools do not assess this type of IPV. Four questions to assess transgender-related IPV (T-IPV) were developed: (a) being forced to conform to an undesired gender presentation or to stop pursuing gender transition; (b) being pressured to remain in a relationship by being told no one would date a transgender person; (c) being "outed" as a form of blackmail; and (d) having transition-related hormones, prosthetics, or clothing hidden or destroyed. The T-IPV tool was administered to 150 female-to-male transmasculine individuals completing a study of cervical cancer screening in Boston from March 2015-September 2016. Construct validity was assessed by examining correlations between T-IPV and two validated screeners of other forms of IPV (convergent) and employment status and fruit consumption (divergent). The association between T-IPV and negative health outcomes (posttraumatic stress disorder [PTSD], depression, psychological symptoms, binge drinking, number of sexual partners, and sexually transmitted infection [STI] diagnosis) were also calculated. Lifetime T-IPV was reported by 38.9%, and 10.1% reported past-year T-IPV. T-IPV was more prevalent among those who reported lifetime physical (51.7% vs. 31.7%, p = .01) and sexual (58.7% vs. 19.4%, p < .001) IPV than those who did not. Lifetime T-IPV was associated with PTSD (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI] = [1.04, 4.80]), depression (AOR = 2.70, 95% CI = [1.22, 5.96]), and psychological distress (AOR = 2.82, 95% CI = [1.10, 7.26]). The T-IPV assessment tool demonstrated adequate reliability and validity and measures a novel type of abuse that is prevalent and associated with significant mental health burden. Future work should further validate the measure and pilot it with male-to-female transfeminine individuals.

Optimizing HIV prevention and care for transgender adults

: Transgender women have recently been acknowledged as a unique and important risk group in HIV research and care. Although transgender men also face specific problems related to HIV infection, less is known about the risk behaviours and HIV prevalence of this important population. This article highlights key issues relating to the epidemiology, prevention, treatment and management of complications of HIV infection in transgender adults living with HIV, and explores future areas for HIV-related research, with the ultimate goal of improving healthcare provision and quality of life for transgender persons worldwide.

Variations in Testing for HIV and Other Sexually Transmitted Infections Across Gender Identity Among Transgender Youth

Purpose: Transgender youth are at high risk for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), but their rates of screening are unknown. This study sought to quantify HIV and other STI testing levels and to examine variations in testing levels across three categories of gender identity: transgender men, transgender women, and nonbinary individuals. Methods: Between June 2017 and June 2018, 186 transgender youth aged 15-24 years were recruited into a randomized trial of home HIV testing supplemented with telehealth-based counseling. Information on sociodemographics, health care utilization, sexual activity, stress and resilience, and history of HIV and other STI testing was obtained. Multivariable logistic regression models were formulated to identify variations in testing for HIV and other STIs across gender identities. Results: Twenty-eight of 186 participants (15.1%) reported testing for HIV in the past year, and 42 (22.6%) reported testing for other STIs. Transgender women were less likely to have been tested for HIV (adjusted odds ratio [aOR]: 0.15, 95% confidence interval [CI]: 0.03-0.78) and other STIs (aOR: 0.33, 95% CI: 0.11-0.99), but nonbinary individuals were equally likely to have been tested compared with transgender men. Participants who agreed that their health care provider is knowledgeable about transgender health issues were thrice as likely to have been tested for HIV (aOR: 3.29, 95% CI: 1.36-7.97) and other STIs (aOR: 3.05, 95% CI: 1.40-6.63) compared with those who disagreed. Conclusion: Low levels of testing among transgender youth highlight the exigency of improving gender- and age-appropriate HIV and other STI prevention services. Given that provider knowledge of transgender health issues was strongly associated with testing, training health care providers in transgender-related care could prove beneficial.

A Pre-Exposure Prophylaxis Adherence Intervention (LifeSteps) for Young Men Who Have Sex With Men: Protocol for a Pilot Randomized Controlled Trial

Background

New HIV infections occur at a disproportionately high rate among young men who have sex with men (YMSM). It is, therefore, essential that comprehensive HIV prevention strategies, specifically tailored to their needs and perceptions, are developed, tested, and disseminated. Antiretroviral pre-exposure prophylaxis (PrEP) is effective in decreasing HIV transmission among men who have sex with men; however, adherence is critical to its efficacy. In open-label studies among YMSM, adherence was suboptimal. Hence, behavioral approaches that address the unique challenges to YMSM PrEP adherence are needed.

Objective

This study aims to describe the protocol for intervention refinement and a pilot randomized controlled trial (RCT) of a PrEP adherence intervention, LifeSteps for pre-exposure prophylaxis for young men who have sex with men (LSPY).

Methods

This study includes the following 2 phases: formative qualitative interviews with approximately 20 YMSM and 10 key informants for intervention adaptation and refinement and a pilot RCT of up to 50 YMSM to assess the feasibility, acceptability, and preliminary efficacy of the LSPY, compared with the PrEP standard of care, to improve PrEP adherence. Participants will be recruited at 3 iTech subject recruitment venues in the United States.

Results

Phase 1 is expected to begin in June 2018, and enrollment of phase 2 is anticipated to begin in early 2019.

Conclusions

Few rigorously developed and tested interventions have been designed to increase PrEP adherence among YMSM in community settings, despite this population’s high HIV incidence. The long-term goal of this intervention is to develop scalable protocols to optimize at-risk YMSM’s PrEP uptake and adherence to decrease the HIV incidence.

International Registered Report Identifier (IRRID)

DERR1-10.2196/10661

Condom use social norms and self-efficacy with different kinds of male partners among Chinese men who have sex with men: results from an online survey

Background

Social norms and self-efficacy play important roles in promoting consistent condom use among men who have sex with men (MSM). Few studies have investigated the association between social norms, self-efficacy and consistent condom use with different kinds of male partners among MSM. We conducted an online survey of MSM to evaluate this in China.

Methods

A cross-sectional online survey was conducted in 2015. Participants completed a validated questionnaire covering socio-demographic information, consistent condom use, condom use social norms and self-efficacy. Eligible participants were 16 or older, born biologically as a male, engaged in anal sex with a man at least once during their lifetime, engaged in condomless anal or vaginal sex in the last three months. In this study, we further restricted to people who had sex with male partners in the last three months. Participants were classified into three groups: engaged in sex only with regular partners, engaged in sex only with casual partners and engaged in sex with both regular partners and casual partners.

Results

Participants were recruited from 32 provinces in China. Among 1057 participants, 451(42.7%), 217(20.5%), and 389(36.8%) engaged in sex with regular partners only, casual partners only and both types in the last three months, respectively. Men engaged in sex only with regular partners in the last three months had a higher condom use self-efficacy than with other two types of partners (P < 0.01). Both social norms (regular partners: adjusted OR:1.59, 95% CI: 0.97–2.60; casual partners: adjusted OR: 1.58, 95% CI: 1.19–2.09; both types: adjusted OR: 1.48, 95% CI: 1.13–1.95) and self-efficacy (regular partners: adjusted OR: 2.88, 95% CI: 1.59–5.22; casual partners: adjusted OR: 2.35, 95% CI: 1.69–3.26; both types: adjusted OR: 2.45, 95% CI: 1.81–3.32) were positively associated with consistent condom use. No interaction effect was detected between condom social norms and self-efficacy on consistent condom use among Chinese MSM (p > 0.05).

Conclusions

Both social norms and self-efficacy were positively correlated with consistent condom use with any types of partners among Chinese MSM. Tailored interventions that aimed to improve social norms and self-efficacy has the potential to improve overall condom use among Chinese MSM.

Trial registration

ClinicalTrials.gov: NCT02516930. August 6, 2015.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6090-5) contains supplementary material, which is available to authorized users.

University of North Carolina/Emory Center for Innovative Technology (iTech) for Addressing the HIV Epidemic Among Adolescents and Young Adults in the United States: Protocol and Rationale for Center Development

Background

Over a fifth of all new HIV infections in the United States occur among persons aged 13 24 years, with most of these diagnoses occurring among gay and bisexual males (81%). While the epidemic of HIV in the United States has leveled off for many age groups, the annual number of new HIV diagnoses among young men who have sex with men (YMSM; 13-24 years old) remains high. Traditional approaches to continuum improvement for youth have been insufficient, and targeted interventions are urgently needed for young people at risk for or infected with HIV. Interventions delivered through mobile health technology represent a promising approach for improving outcomes in this population. Mobile phones have nearly reached saturation among youth, making mobile technology a particularly promising tool for reaching this population.

Objective

The University of North Carolina/Emory Center for Innovative Technology (iTech) is a National Institutes of Health cooperative agreement as part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. iTech aims to impact the HIV epidemic by conducting innovative, interdisciplinary research on technology-based interventions across the HIV prevention and care continuum for adolescents and young adults in the United States, particularly YMSM, by providing the following: (1) evaluation of novel approaches to identifying youth with undiagnosed HIV infections; (2) evaluation of multilevel, combination prevention approaches, particularly relevant to gender- and sexual-minority youth facing co-occurring health risks; (3) evaluation of uptake of and adherence to biomedical prevention modalities; and 4) evaluation of interventions designed to promote or optimize engagement in care and antiretroviral therapy adherence in HIV-positive youth, to optimize viral load suppression.

Methods

iTech brings together multidisciplinary experts in the fields of adolescent HIV treatment and prevention, development and evaluation of technology-based interventions, HIV surveillance and epidemiology, and intervention design and evaluation. This initiative will support 8 efficacy trials and 2 exploratory projects, each led by 2 principal investigators. Taken together, the studies address all of the key steps of the HIV prevention and care continuum for youth in the United States. Each proposal uses technology in a scientifically rigorous and innovative way to access, engage, and impact at-risk or infected youth. Nine iTech subject recruitment venues are spread across 8 US cities. Three cores (management, analytic, and technology) support all iTech activities and form the research network’s infrastructure, facilitating all aspects of study implementation and evaluation.

Results

Formative work has already begun on many of the above-mentioned iTech trials. We expect the first randomized controlled trials to begin in mid-2018. Additional details can be found in the individual intervention protocol papers in this issue.

Conclusions

Through its comprehensive research portfolio, iTech aims to effectively advance HIV prevention and care for youth through technology-based, youth-relevant interventions that maximize adaptability and sustainability.

Registered Report Identifier

RR1-10.2196/10365

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

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

A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States

Transgender and gender non-conforming (TGNC) populations, including those who do not identify with gender binary constructs (man or woman) are increasingly recognized in health care settings. Research on the health of TGNC people is growing, and disparities are often noted. In this review, we examine 77 studies published between January 1, 1997 and March 22, 2017 which reported mental health outcomes in TGNC populations to (a) characterize what is known about mental health outcomes and (b) describe what gaps persist in this literature. In general, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among TGNC adults. We also used the minority stress model as a framework for summarizing existing literature. While no studies included all elements of the Minority Stress Model, this summary gives an overview of which studies have looked at each element. Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to mental health problems. Social support, community connectedness, and effective coping strategies appear beneficial. We argue that routine collection of gender identity data could advance our understanding mental health risk and resilience factors among TGNC populations.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

HIV Prevalence, Sexual Partners, Sexual Behavior and HIV Acquisition Risk Among Trans Men, San Francisco, 2014

We surveyed 122 trans men using a hybrid sampling method that included randomly selected physical and online venues and peer referral to measure HIV prevalence and risk behaviors. HIV prevalence was 0% (one-sided 97.5% confidence interval 0-3.3%). Of 366 partnerships described, 44.8% were with cisgender women, 23.8% with cisgender men, 20.8% with trans men, and 10.7% with trans women. Condomless receptive anal and front hole/vaginal sex averaged one to three episodes per six months. HIV prevalence in trans men is likely closer to heterosexual cisgender men and women in San Francisco than trans women or MSM. Prevention prioritizing trans women and MSM, coupled with individualized and relevant sexual health education for trans men with partners from these populations, may best address the HIV prevention needs of trans men. Systematic collection of transgender status in Census and health data is needed to understand other health disparities among trans men.

Integrated and Gender-Affirming Transgender Clinical Care and Research

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

A Review of Contemporary Assessment Tools for Use with Transgender and Gender Nonconforming Adults

There is increasing recognition of the need for culturally sensitive services for individuals who identify as transgender or gender non-conforming (TGNC), and only recently have empirical studies appeared in the literature that inform best practices for TGNC people. Competent, culturally appropriate clinical services and research depend upon methodologically sound assessment of key constructs, but it is unclear whether appropriate self-report or clinician-rated assessment tools for adults exist. This paper reviewed existing published measures to identify areas of strength as well as existing gaps in the available research. The search strategy for this systematic review identified any published paper describing a self-report or clinician-rated scale for assessing transgender-related concerns. Each measure was reviewed for information on its scope, reliability, validity, strengths, limitations, and source. The majority of these questionnaires were developed with the TGNC communities and targeted important factors that affect quality of life for TGNC people. Limitations included limited evidence for validity, reliability, and sensitivity to change. Overall, the field is moving in the direction of TGNC-affirming assessment, and promising measures have been created to monitor important aspects of quality of life for TGNC people. Future research should continue to validate these measures for use in assessing clinical outcomes and the monitoring of treatment progress.

Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital

BACKGROUND

Suicidal ideation is understudied among men who have sex with men (MSM) across Sub-Saharan Africa.

AIMS

This study aimed to explore social capital and sexual behavior stigma associated with suicidal ideation among MSM in the West African nations of The Gambia, Burkina Faso and Togo.

METHODS

Participants were recruited using respondent-driven sampling and snowball sampling across multiple cities (n = 1555) from July 2011 to August 2013. During a single study visit, participants completed a survey. Logistic regression models were used to assess bivariate and multivariable associations with suicidal ideation.

RESULTS

The prevalence of lifetime suicidal ideation was 13% overall and ranged 6%-17% across study sites. After adjusting for potential confounders, MSM who reported stigma as a result of having sex with men were more likely to report suicidal ideation. Physical and sexual violence was strongly associated with suicidal ideation, including being physically harmed (adjusted odds ratio (aOR) = 2.94, 95% confidence interval (CI) = 1.91, 4.52), tortured (aOR = 3.86, 95% CI = 2.17, 6.86) and raped (aOR = 3.07, 95% CI = 2.05, 4.60). In contrast, increasing social participation with the broader community was associated with decreased report of suicidal ideation (aOR = 0.91, 95% CI = 0.85, 0.99).

CONCLUSION

Sexual behavior stigma should be addressed to improve mental health among MSM in Western Sub-Saharan Africa.

The role of gender affirmation in psychological well-being among transgender women

High prevalence of psychological distress, including greater depression, lower self-esteem, and suicidal ideation, has been documented across numerous samples of transgender women and has been attributed to high rates of discrimination and violence. According to the gender affirmation framework (Sevelius, 2013), access to sources of gender-affirmative support can offset such negative psychological effects of social oppression. However, critical questions remain unanswered in regards to how and which aspects of gender affirmation are related to psychological well-being. The aims of this study were to investigate the associations between three discrete areas of gender affirmation (psychological, medical, and social) and participants' reports of psychological well-being. A community sample of 573 transgender women with a history of sex work completed a one-time self-report survey that assessed demographic characteristics, gender affirmation, and mental health outcomes. In multivariate models, we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem while no domains of affirmation were significantly associated with suicidal ideation. Findings support the need for accessible and affordable transitioning resources for transgender women in order to promote better quality of life among an already vulnerable population. As the gender affirmation framework posits, the personal experience of feeling affirmed as a transgender person results from individuals' subjective perceptions of need along multiple dimensions of gender affirmation. Personalized assessment of gender affirmation may thus be a useful component of counseling and service provision for transgender women.