Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

Parenthood and the Physical and Mental Health of Sexual and Gender Minority Parents: A Cross-Sectional, Observational Analysis from The PRIDE Study

PURPOSE

To compare the physical and mental health of sexual and gender minority (SGM) parents to SGM non-parents.

METHODS

A cross-sectional analysis using 2018-2020 data from The PRIDE Study, a national longitudinal cohort of SGM adults. We used Poisson regression adjusted for age, gender, relationship status, race/ethnicity, household income, and education to assess the association between parental status and each outcome.

RESULTS

Among 9,625 SGM participants, 1,460 (15%) were parents. Older participants were more likely to be parents: 2% of participants aged 18-30, 18% aged 30-39, and 38% aged 40+ were parents. In adjusted analyses, parenthood was associated with greater depression, anxiety, and post-traumatic stress symptoms as well as ever cigarette smoking. Among individuals assigned female sex at birth, parents were twice as likely to have been diagnosed with pelvic inflammatory disease compared to non-parents. There was no association between parenthood status and alcohol use, substance use, diabetes, HIV, hypertension, or autism.

CONCLUSIONS

In this national cohort of SGM adults, parenthood was associated with differences in physical and mental health measures. Understanding how parenthood influences the health and well-being of the estimated 3 million SGM parents in the US will help our health systems support diverse families.

Transgender Health Dilemmas: An Intersectional Analysis of the Therapeutic Itineraries of Transgender Communities in the Philippines

This study leverages an intersectional lens to characterize the therapeutic itineraries of local transgender (trans) communities vis-à-vis salient cisnormative and capitalist structures in Philippine society that produce trans health inequities. Interpretative phenomenological analysis of online interviews with thirteen (13) self-identified trans Filipinos reveals how the inaccessibility of trans-responsive care in the Philippines fosters trans health dilemmas, or the dilemmatic decision-making circumstances and processes that force trans Filipinos to choose between their trans-specific health needs and other needs. Such dilemmas valorize the deprioritization of trans health, disengagement with the health system, and the pursuit of alternative pathways to care oftentimes at the expense of their overall well-being. Addressing these dilemmas entails research, policy, and advocacy work that contend with the implicated structures of domination through systemic interventions initiated in partnership with local trans communities.

Women's rugby for all: Toward an intersectional women's rugby research agenda

Women rugby players are participating in the sport at the highest levels to date. However, despite this increase in participation, sports sciences and sports medicine/sports physiotherapy (SEMS) research output has not mirrored this increase. Females have hormonally mediated anatomical and physiological profiles, which may have implications for rugby performance, injury risk and rehabilitation outcomes. However, hormonal fluctuations and the physiological differences between the sexes are not the only contributors to sex-related differences in the rugby experience. Rugby is a highly gendered environment, which operates within a hegemonic masculine norm and marginalises female and women athletes. Further, while women players in general are underrepresented in sports sciences and SEMS research, women rugby players and experts from ethnic minorities and the Global South are near invisible in the literature as they are marginalised on multiple fronts. Sports sciences and SEMS research should take an intersectional lens to investigate the joint relationship between the various sources of inequity in rugby. Intersectional research in women rugby players would encourage the conceptualisation and analysis of the complex social inequalities that the most marginalised women players and those who simultaneously negotiate multiple identities experience. Such data can better inform federation-level interventions and policy changes to address the needs of historically marginalised player populations as our research portfolio will be more representative of the world's rugby population.

A thematic analysis of disinformation in gender-affirming healthcare bans in the United States

CONTEXT

Bans on gender-affirming care (GAC) for transgender and gender-expansive (TGE) people are grounded in scientific disinformation and have been challenged in American courts.

METHODS

Five legal filings by state officials in defense of GAC restriction from initial litigation were analyzed using reflexive thematic analysis. Themes and subthemes of disinformation were identified after review and analysis of these filings.

FINDINGS

Five themes of disinformation emerged: False and misleading claims about (1) gender dysphoria and gender identity, (2) the evidence regarding GAC, (3) standard practice of GAC, (4) the safety of GAC, and finally, (5) rejection of medical authority. These themes were well represented across the analyzed documents.

CONCLUSIONS

The five disinformation themes and subthemes have been noted in lower courts, but have seen some purchase in appellate courts, suggesting that medical disinformation in law may have far-reaching consequences for medical policy.

Identity Matters: Religious Experiences of US based Transgender Young People

Research centered on the socioemotional benefits of religion and religious congregations for young people has highlighted largely positive outcomes for both young people and religious congregations. However, fewer studies have explored whether transgender young people receive those same socioemotional benefits from being religiously affiliated. Using secondary quantitative data from the 2015 US Transgender Survey, this study examined the religious experiences of transgender young people (aged 18-24). The data indicate that individual demographics (e.g., race, gender identity, sexual orientation, religious affiliation) affected the religious experiences of transgender young people, including leaving their congregations due to the fear of being rejected. More research is needed on the socioemotional benefits of religious affiliation for transgender young people.

An ecological analysis of hope amongst Asian rainbow young people in Aotearoa New Zealand

Rainbow research tends to prioritise gender and sexuality experiences over the racialised experiences of Asian rainbow young people. Informed by an intersectional lens, we employed a hope-based ecological framework to examine how multiple overlapping axes of oppression (e.g. cisgenderism, heterosexism and racism) shape the aspirations of these youth. We drew on the voices of Asian participants from the 2021 Aotearoa New Zealand Identify Survey, who had responded to an open-text question on their hopes for rainbow young people (n = 217; age range = 14 to 26). The content analysis identified seven prominent categories of hope across three ecological levels (macro exo and meso). These categories were societies: 1) break away from cisheterosexist expectations; 2) confront racism and intersection with cisheterosexism; 3) promote rainbow-inclusive education; 4) ban sexual orientation and gender identity change efforts; 5) improve access to culturally safe health care; 6) dismantle white-dominated rainbow spaces; and 7) provide more rainbow-inclusive family support. These hopes were constructed amidst the desire to challenge unacceptance and exclusion by the wider society for not adhering to white cisheterosexist expectations. The study provides critical insights for community organisations, education settings, and government to consider in addressing the diverse needs of Asian rainbow young people.

Predictors of Adolescent Intimate Partner Sexual Violence Victimization: Patterns of Intersectional Social Positions in a Statewide, School-based Sample

Intimate partner sexual violence (IPSV) is a substantial public health issue faced by youth, with disparities along lines of race, gender, and sexual orientation. Using an intersectional framework, the current study describes the prevalence of self-reported IPSV victimization across intersecting social positions among adolescents. High school students who completed the 2019 Minnesota Student Survey were asked whether they had ever experienced IPSV. Using exhaustive Chi-Square Automatic Interaction Detection (eCHAID), responses were modeled using five indicators: racial/ethnic identity, transgender/genderqueer/genderfluid identity, sex assigned at birth, sexual orientation, and school location. The prevalence of IPSV victimization within each end group identified by the eCHAID varied from 2.6% to 32.0%. The highest prevalence of IPSV among all students was observed in subgroups defined by multiple marginalized social positions; for example, 32.0% among lesbian, gay, bisexual, queer, pansexual, or questioning (LGBQ+) students of color who were transgender, genderqueer, genderfluid or unsure of their gender, and assigned male at birth; 22.8% among LGBQ+ students assigned female at birth and enrolled in a Greater Minnesota (outside of the Twin Cities) school; and 22.2% among Native+ or missing race LGBQ+ students assigned female at birth and enrolled in a metropolitan school. Within the eCHAID decision tree, several subsamples of students were split into two more subsamples with a twofold or greater statistically significant difference in IPSV victimization prevalence between them. Findings from this study highlight notable disparities in the prevalence of IPSV victimization among Minnesota youth and demonstrate the importance of detailing the distribution of interpersonal violence outcomes across youth with multiple marginalized identities. Findings suggest that disparities reported along one categorical axis only may miss important nuances in how risk for IPSV is distributed. Population health researchers should utilize methods that allow for the explication of complex intersections that characterize individuals' social positions in estimating the prevalence of sexual violence.

A call for health justice: Striving toward health equity at a community health center

Community health centers play a key role in promoting health justice and equity. Health justice, which is the attainment of health equity, or the fair, unambiguous, and non-arbitrary distribution of all health resources necessary for optimal health of the individual, family, and community, is necessary to optimize their wellbeing and to build healthy communities. Community-based health centers are well-positioned to lead in these efforts, as they connect with, seek to understand, and innovatively serve communities that experience complex health-related needs and are differentially impacted by structural vulnerabilities (i.e., racism). The purpose of this article is to present a nurse-led model of culturally responsive health care that is rooted in partnerships designed to address medical and health-related social needs. Current health inequities in the United States across constructs of race and socioeconomic status warrant comprehensive healthcare models that explicitly incorporate health justice, trauma-informed, and antiracist approaches into practice, especially when serving high/complex-need and under-resourced communities. Foundationally, it is imperative that these models of care strive toward equity regarding access to compassionate, affordable, culturally relevant health care; center community members' voices and guidance; promote growth and development of staff in understanding structural barriers and act to dismantle them; and create learning opportunities for students and staff to understand and address social determinants of health to provide high-quality care, with an ultimate goal to improve community health.

Pregnancy experiences of transgender and gender-expansive individuals: A systematic scoping review from a critical midwifery perspective

BACKGROUND

Evidence suggests that transgender and gender-expansive people are more likely to have suboptimal pregnancy outcomes compared with cisgender people. The aim of this study was to gain a deeper understanding of the role of midwifery in these inequities by analyzing the pregnancy experiences of transgender and gender-expansive people from a critical midwifery perspective.

METHODS

We conducted a systematic scoping review. We included 15 papers published since 2010 that reported on pregnancy experiences of people who had experienced gestational pregnancy at least once, and were transgender, nonbinary, or had other gender-expansive identities.

RESULTS

Three themes emerged from our analysis: "Navigating identity during pregnancy," "Experiences with mental health and wellbeing," and "Encounters in the maternal and newborn care system." Although across studies respondents reported positive experiences, both within healthcare and social settings, access to gender-affirmative (midwifery) care and daily social realities were often shaped by trans-negativity and transphobia.

DISCUSSION

To improve care outcomes of transgender and gender-expansive people, it is necessary to counter anti-trans ideologies by "fixing the knowledge" of midwifery curricula. This requires challenging dominant cultural norms and images around pregnancy, reconsidering the way in which the relationship among "sex," "gender," and "pregnancy" is understood and given meaning to in midwifery, and applying an intersectional lens to investigate the relationship between gender inequality and reproductive inequity of people with multiple, intersecting marginalized identities who may experience the accumulated impacts of racism, ageism, and classism. Future research should identify pedagogical frameworks that are suitable for guiding implementation efforts.

Intersectionality and challenges in support for chest-feeding transgender men

This article tried, from an intersectional standpoint, to grasp the challenges experienced by health professionals and service users of human milk banks in provision of care for transgender men chestfeeding. This exploratory, descriptive qualitative study drew on interviews of six human milk bank staff, who had previously assisted trans men in relation to chestfeeding and two bisexual trans men, who chestfed. The data was treated by thematic analysis, supported by Atlas.ti software, version 9.0. Lacunas in the educational, institutional and management spheres, associated with personal and social issues, reproduce a pre-conceived normative model and disregard the special demands of providing chestfeeding care for the trans population. Cisheteronormativity and "professional supremacy" operate in personal, social and institutional respects to segregate transgender men in lactation support services. Intersectional analysis of these challenges affords an overall view of segregative factors and enables public policies to be introduced to promote social justice.

Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women

BACKGROUND

Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants.

METHODS

Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots.

RESULTS

In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color.

CONCLUSIONS

The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Health status of transgender people globally: A systematic review of research on disease burden and correlates

BACKGROUND AND OBJECTIVES

Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality.

DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS

We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis.

RESULTS

The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality.

CONCLUSIONS AND IMPLICATIONS

Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants.

REGISTRATION

PROSPERO CRD42021234043.

Experiences of transgender persons in accessing routine healthcare services in India: Findings from a participatory qualitative study

Despite having a higher burden of health problems, transgender persons face challenges in accessing healthcare in India. Most studies on healthcare access of transgender persons in India focus only on HIV related care, mental healthcare, gender affirmative services or on the ethno-cultural communities or transgender women. This study fills this gap by focusing on diverse gender identities within the transgender community with a specific focus on experiences in accessing general or routine healthcare services. A qualitative descriptive approach was used in this study. 23 in-depth interviews and 6 focus group discussions were conducted virtually and in-person with a total of 63 transgender persons in different regions of India between May and September 2021. The study used a community-based participatory research approach and was informed by the intersectionality approach. Thematic analysis was conducted to analyze the data. Four key themes emerged: (i) intersectional challenges in accessing healthcare start outside of the health system, continue through cisgender-binary-normative health systems that exclude transgender persons; and at the interface with individuals such as health professionals, support staff and bystanders; (ii) the experiences negatively impact transgender persons at an individual level; (iii) in response, transgender persons navigate these challenges across each of the levels: individual, health system level and from outside of the health system. This is a first of its kind qualitative participatory study focusing on routine healthcare services of transgender persons in India. The findings indicate the need to move conversations on trans-inclusion in healthcare from HIV and gender affirmative services to routine comprehensive healthcare services considering the higher burden of health problems in the community and the impact of poor access on their lives and well-being.

Multilevel experiences of carceral violence in Los Angeles, California: first-hand accounts from a racially diverse sample of transgender women

Transgender women face a disproportionate burden of carceral violence, or violence related to policing and the criminal legal system, with transgender women of colour experiencing even greater disparities. Several frameworks conceptualise the mechanisms through which violence impacts transgender women. However, none of them directly explore the role of carceral violence, particularly as it is experienced by transgender women themselves. Sixteen in-depth interviews were conducted with a racially/ethnically diverse sample of transgender women in Los Angeles between May and July 2020. Participants were between 23 - 67 years old. Participants identified as Black (n = 4), Latina (n = 4), white (n = 2), Asian (n = 2), and Native American (n = 2). Interviews assessed experiences of multilevel violence, including from police and law enforcement. Deductive and inductive coding methods were used to identify and explore common themes concerning carceral violence. Experiences of law enforcement-perpetrated interpersonal violence were common and included physical, sexual and verbal abuse. Participants also highlighted structural violence, including misgendering, the non-acceptance of transgender identities, and police intentionally failing to uphold laws that could protect transgender women. These results demonstrate the pervasive, multilevel nature of carceral violence perpetrated against transgender women and suggest avenues for future framework development, trans-specific expansions of carceral theory, and system-wide institutional change.

Parkinson's Disease Inequities in Daily Cognitive Activities: An Intersectional Approach

Objective

Intersectionality approaches to examining differences in Parkinson's disease (PD) based on racialized group, gender identity, and socioeconomic status (SES) are not well covered in the literature. Additionally, the differences in daily cognitive activities for persons diagnosed with PD by racialized group, gender, and SES are undetermined. This study was conducted to explore the differences in PD daily cognitive activities for diverse racialized groups by gender and SES.

Methods

This study was a secondary analysis of the Michael J. Fox Foundation's Fox Insight online clinical dataset. Persons with PD were partitioned into 16 racialized by gender groups (Black women, Indigenous men, Latina/x women, Asian men, etc.) that were used in within-group comparisons of low-, middle-, and high-SES-a new variable comprising education and income.

Results

Intersectional analyses revealed most items differed between low-SES and high-SES except for items associated with Black and Indigenous men, for whom significant differential item functioning was found between mid-SES and high-SES.

Conclusions

These findings revealed that within-group differences exist and may be missed in research in which social factors are adjusted for instead of included in the model.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

INTRODUCTION

Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States.

METHODS

Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status.

RESULTS

The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1).

CONCLUSIONS

Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

The intersectional social patterning of early-COVID-era digital intimacies among transgender and gender-diverse young adults: effects on peri-pandemic sexual decision-making

Interactive communications technologies facilitate identity formation and socio-sexual connection among transgender and gender-diverse young people. However, within their communities, variations in technology use along ethno-racial, sexual and gendered lines, and as facilitators of sexual resilience during the early COVID-19 pandemic, remain under-studied. Among N = 230 transgender and gender-diverse young adults, surveyed between October 2020 and September 2021, latent class analyses characterised participants by preferred functional affordances, such as finding dates, sex and friends (Model 1), and by simultaneous account-keeping across social, dating and 'hookup' apps (Model 2). Werron and Ringel's typology of pandemic practices characterised qualitative descriptions of sexual decision-making attributed to COVID-19. Both fit indices favoured two-class solutions. Model 1 detected an n = 89, 43% 'high interactive communications technologies-enabled intimacy' (versus 'low technology-enabled intimacy') class, in which digitally mediated friendships, dates, sexual encounters and gay/lesbian sexualities, predominated. An n = 38, 17% 'high socio-sexual polymedia' (versus 'low polymedia') class in Model 2 was characterised by simultaneous social media, 'hookup' and dating app usage. 'High' subgroups saw statistically significant reductions in sexual partners, with the high polymedia class also associated with reductions in HIV testing. Qualitative results contextualised these reductions as, predominantly, 'responsive' pandemic practices: reactions to stay-at-home orders.

Gender affirmation and mental health in prison: A critical review of current corrections policy for trans people in Australia and New Zealand

BACKGROUND

Trans people in prison experience disproportionate rates of harm, including negative mental health outcomes, and thus require special protections. Instead, corrections policies have historically further marginalised them. This critical policy review aimed to compare corrections policies for trans people in Australia and New Zealand with human rights standards and consider their mental health impact.

METHODS

Online searches were conducted on corrections websites for each state/territory in Australia and New Zealand. Drawing on the Nelson Mandela Rules and Yogyakarta Principles, 19 corrections policies relevant to placement, naming, appearance and gender-affirming healthcare for trans people were reviewed. The potential mental health impact of these policies on incarcerated trans people was discussed using the Gender Minority Stress and Resilience framework.

RESULTS

Australian and New Zealand corrections policies have become more concordant with human rights standards in the past 5 years. However, gender-related discrimination and human rights violations were present in corrections policies of all jurisdictions. New South Wales and Victorian policies had the highest concordance with human rights standards, while Queensland and South Australian policies had the lowest.

CONCLUSION

Policies that contribute to discrimination and minority stress may increase risk of mental health problems and suicide for incarcerated trans people. Mental health professionals working in prisons need to be aware of these risks to provide safe and accessible mental healthcare for trans people. Collaborative policy development with trans people is essential to protect the safety and rights of incarcerated trans people and consider models beyond the gender binary on which correctional systems have been founded.

Stigma, social and structural vulnerability, and mental health among transgender women: A partial least square path modeling analysis

INTRODUCTION

Existing literature suggests that transgender women (TW) may be at high risk for adverse mental health due to stress attributed to combined experiences of stigma and complex social and structural vulnerabilities. Little research has examined how these co-occurring experiences relate to mental health. We aimed to test a theoretically driven conceptual model of relationships between stigma, social and structural vulnerabilities, and mental health to inform future intervention tailoring.

DESIGN/METHODS

Partial least square path modeling followed by response-based unit segmentation was used to identify homogenous clusters in a diverse community sample of United States (US)-based TW (N = 1418; 46.2% White non-Hispanic). This approach examined associations between latent constructs of stigma (polyvictimization and discrimination), social and structural vulnerabilities (housing and food insecurity, unemployment, sex work, social support, and substance use), and mental health (post-traumatic stress and psychological distress).

RESULTS

The final conceptual model defined the structural relationship between the variables of interest within stigma, vulnerability, and mental health. Six clusters were identified within this structural framework which suggests that racism, ethnicism, and geography may be related to mental health inequities among TW.

CONCLUSION

Our findings around the impact of racism, ethnicism, and geography reflect the existing literature, which unfortunately shows us that little change has occurred in the last decade for TW of color in the Southern US; however, the strength of our evidence (related to sampling structure and sample size) and type of analyses (accounting for co-occurring predictors of health, i.e., stigma and complex vulnerabilities, reflecting that of real-world patients) is a novel and necessary addition to the literature. Findings suggest that health interventions designed to offset the negative effects of stigma must include anti-racist approaches with components to reduce or eliminate barriers to resources that contribute to social and structural vulnerabilities among TW. Herein we provide detailed recommendations to guide primary, secondary, and tertiary prevention efforts.

CLINICAL RELEVANCE

This study demonstrated the importance of considering stigma and complex social and structural vulnerabilities during clinical care and design of mental health interventions for transgender women who are experiencing post-traumatic stress disorder and psychological distress. Specifically, interventions should take an anti-racist approach and would benefit from incorporating social support-building activities.

Gender-Based Violence and Suicide Among Gender-Diverse Populations in the United States

OBJECTIVES

Transgender populations report higher suicidal ideation (SI) and suicide attempts than the general population. This study sought to identify predictors of suicide in individuals with diverse gender identities, including transgender women; transgender men; and gender-nonbinary, genderqueer, and crossdressing individuals within various racial/ethnic groups.

METHODS

Secondary analyses were conducted using the United States Transgender Survey (N = 27,204). The dependent variables were SI and suicide attempts in the past 12 months. The independent variables were gender, race, employment status, transactional sex, exposure to violence, and age. Bivariate, multivariable, and nested models were used to examine the association between variables.

RESULTS

Findings reveal transgender women to be more likely to report SI than other gender groups. White and Hispanic/Latino participants were more likely to have SI than Black participants. Transgender men and gender-nonbinary groups were significantly less likely to attempt suicide than transgender women, and crossdressers were not significantly different in suicide attempts than transgender women. Increased exposure to violence was associated with increased SI and suicide attempts. Increased age and part- or full-time employment were associated with decreased SI and suicide attempts. White transgender women were more likely to have attempted suicide than white transgender men and gender-nonbinary groups. Asian and biracial transgender women were more likely to have attempted suicide than the other gender groups.

CONCLUSIONS

Findings illuminate differences in suicide among individuals with diverse racial and gender identities and support the call for continued research on mental health experiences of these populations.HighlightsSuicide ideation and attempts varies by race and gender, including for people with diverse gender identitiesTransgender women and crossdressers are more likely to have attempted suicide than transgender men or gender-nonbinary individualsSuicide ideation and suicide attempts are associated with gender, race, employment, survival and transactional sex, violence exposure, and age.

"Nowhere else to be found": Drawing on peer support experiences among transgender and gender-diverse people to substantiate community-driven gender-affirming care

Increasingly, applied social scientists and clinicians recognize the value of engaging transgender and gender-diverse (TGD) people, particularly TGD individuals with lived experience as care recipients (peers), to inform the provision of gender-affirming care. Despite this trend, few researchers have systematically examined how this group can contribute to and enhance the development and delivery of interventions intended to affirm gender diversity. In this article, we address limitations in the literature by drawing on a secondary analysis of qualitative data - originally collected to examine the peer support experiences of TGD individuals - to explore the potential that TGD peers hold for elevating gender-affirming care. The study was informed methodologically by an abductive approach to grounded theory, and conceptually by critical resilience and intersectional scholarship. Data collection involved virtual, semi-structured interviews with 35 TGD individuals in two Canadian cities who indicated having experiences of seeking, receiving, and/or providing peer support. Data analysis comprised an iterative, abductive process of cross-referencing participant accounts with relevant scholarship to arrive at an account of how TGD peers may contribute to the growth of gender-affirming care. Our findings suggest, broadly, that TGD peers may enhance gender-affirming care by: (1) validating a growing diversity of embodiments and experiences in healthcare decision-making, (2) nurturing and diversifying relevant networks of safety, community support, and advocacy outside formal systems of care, and (3) strengthening possibilities for resisting and transforming existing healthcare systems. After outlining these findings, we briefly consider the implications of our analysis and leverage our inferences to substantiate the notion of community-driven gender-affirming care, meaning care that is intentional in its incorporation of relevant community stakeholders to shape governance and service provision. We conclude with reflections on the promise of community-driven care at a time of heightened volatility across systems serving TGD populations.

"I felt special!": a qualitative study of peer-delivered HIV self-tests, STI self-sampling kits and PrEP for transgender women in Uganda

INTRODUCTION

Peer delivery is a client-centred approach that could maximize the coverage and impact of HIV services for transgender women (TGW). We conducted qualitative interviews to examine how peer-delivered HIV self-testing (HIVST), sexually transmitted infection self-sampling (STISS) and oral pre-exposure prophylaxis (PrEP) influenced prevention choices among TGW and their intimate partners in Uganda.

METHODS

Within a cluster randomized trial of peer-delivered HIVST, STISS and PrEP among HIV-negative TGW (NCT04328025), we conducted 55 qualitative interviews with 30 TGW, 15 intimate partners and 10 TGW peers (August 2021-February 2022). TGW interviews explored: (1) HIV self-test and PrEP experiences; (2) HIVST with intimate partners; and (3) descriptions of self-sampling for STI testing. Partner interviews covered: (1) experiences with HIVST; (2) disclosure of HIV status to intimate partner; and (3) descriptions of sexual behaviours after testing. Peer interview topics included: (1) intervention delivery experiences; and (2) recommendations for peer-delivered HIV prevention services to TGW, including psychological support and coping strategies. Qualitative data were analysed using an inductive content analytic approach.

RESULTS

Peer-delivered combination prevention was valued by this group of TGW and their partners. (1) Peer services extended beyond delivering HIV/STI kits and PrEP refills to caring for individual health and wellbeing by providing stigma coping strategies. Peer psychosocial support empowered research participants to become "HIVST ambassadors," teach non-study TGW about self-testing and PrEP, and encourage linkage to care. (2) HIVST with intimate partners and mutual disclosure of HIV status strengthened partnered relationships. PrEP use after both partners tested HIV negative implied infidelity. (3) Self-sampling enabled TGW to take control of their STI testing and avoid the embarrassment of exposing their bodies. Privacy and confidentiality motivated the uptake of STI testing and treatment.

CONCLUSIONS

In this sample of TGW from Uganda, peer delivery of HIVST, STISS and PrEP refills benefitted individual prevention efforts and extended to a new linkage of TGW not engaged in care. Integrating peer services into differentiated PrEP delivery could increase HIV/STI test coverage and PrEP use in this vulnerable population.

Demographic factors associated with healthcare avoidance and delay in the transgender population: Findings from a systematic review

Purpose

Healthcare avoidance and delay (HAD) in the transgender population has been well documented, and research has explored a range of associated factors that help to identify those most at risk of HAD. This review addresses a gap in the research by synthesizing research exploring associations between HAD and demographic factors.

Methods

A systematic search of literature published at any time up to December 2021 was conducted, using five databases (EBSCO, EMBASE, PubMed, Scopus, and Web of Science) and manually searching reference lists of included studies. After exclusion of duplicates, 608 unique records were subjected to double screening. Papers reporting statistical analyses of HAD in association with any sociodemographic variables were included in this review. Papers consisted of nineteen cross-sectional studies. Narrative synthesis was used to address findings.

Results

Nineteen studies met inclusion criteria, exploring HAD in association with a wide range of demographic factors, including sex and gender, social transition factors, age, race and ethnicity, socioeconomic factors, veteran status, education, sexuality, relationship status, citizenship, place of residence, and state demographics. Findings identified intra-community demographic risk factors, with consistent evidence for increased HAD among transmasculine, and younger, participants. Lower income and higher educational attainment were also associated with increased HAD, while remaining areas had weak or little evidence for association with HAD.

Conclusion

This review expands knowledge in this area by highlighting demographic factors associated with increased HAD in research literature, and exploring how these may be further investigated to address substantial gaps in the body of research.

Exploring gender euphoria in a sample of transgender and gender diverse patients at two U.S. urban community health centers

Transgender and gender diverse (TGD) people are affected by mental health inequities. Gender euphoria-positive emotions or joy in gender-may be associated with positive mental health. Between February 2019-July 2021, we surveyed 2,165 adult TGD patients (median age = 28 years; 29.2 % people of color; 29.6 % nonbinary; 81.0 % taking hormones) evaluating gender euphoria and mental health. Overall, 35.0 % self-reported gender euphoria, 50.9 % gender dysphoria, 23.5 % alcohol misuse, and 44.5 % resilience. Gender euphoria differed by race, gender, insurance, and hormone use, and was associated with reduced gender dysphoria (adjusted Odds Ratio[aOR] = 0.58; 95 % confidence interval [95 %CI] = 0.47-0.72) and alcohol misuse (aOR = 0.75; 95 %CI = 0.60-0.95), and increased resilience (aOR = 1.31; 95 %CI = 1.07-1.61). The construct of gender euphoria may be a promising mental health target.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intersectional Examination of Gender-Inclusive Care and Women's Health

Transgender and gender-nonconforming people remain excluded from women's health spaces, and nurses with expertise in women's health best serve their needs when they seek sexual, reproductive, gynecologic, or obstetric care. However, commentary regarding the term "women" and exclusionary policies and behaviors in health care marginalize gender-nonconforming patients and contribute to health disparities. Therefore, the purpose of this article is twofold. First, we review terminology related to gender-nonconforming populations and their known health care needs; provide a brief historical overview of gender and health care; and describe the influence of White supremacist, misogynist, and heteronormative influences in women's health care. Second, we generate a call to action and specifically discuss the responsibilities of nurses and nursing organizations to ensure the provision of gender-equitable and respectful care and generate clinical recommendations for the specialty.

Contending with precarity: Digital pathways to sexual and reproductive healthcare among transgender Filipinos during the COVID-19 pandemic

Stringent lockdowns during the COVID-19 pandemic and the cisnormative framing of sexual and reproductive health (SRH) in the Philippines cultivated precarious access to SRH systems among transgender (trans) communities during the public health crisis. With the shift toward digital health initiatives, this study aimed to explore the experiences of the local trans community in using digital health initiatives (DHIs) to access SRH care and gender-affirming services, information, and providers during the COVID-19 pandemic. Online interviews with 13 self-identified trans Filipinos living in the Philippines during the pandemic were conducted and analyzed using interpretative phenomenological analysis. First, the narratives of trans Filipinos illustrate how DHIs can address discontinuities of care that emerged during the COVID-19 pandemic. However, because of long-standing geographic, economic, and social barriers to trans-responsive healthcare in the Philippines, local trans communities navigate alternative pathways to care established within digital spaces (e.g., social media) by trans individuals and groups. These online communities of care not only connect trans Filipinos to culturally competent and affordable care but also foster a sense of belongingness and support. Taken together, this study underscores the need to go beyond technical access to care to ensure that trans-inclusive and trans-responsive sources and providers of care are made available throughout the healthcare system. As the narratives of trans Filipinos illustrate, the narratives, experiences, and practices within their online communities of care may be the key to actualizing such a healthcare system not only in the Philippines but all over the world.

Binge Drinking and Cannabis Use among Transgender and Gender-Diverse Young Adults in Michigan

Substance use rates are higher among transgender and gender-diverse people than cisgender people. Rates of substance use are also higher among young adults compared with other age groups. However, little research examines substance use among transgender and gender-diverse young adults. This study examines factors associated with binge drinking and cannabis use among transgender and gender-diverse young adults in Michigan. Participants (N = 78; ages 18-25) completed an online survey that included demographics and substance use and related characteristics. Race, stimulant misuse, and sedative misuse were associated with more frequent binge drinking. Older age and past-year pain reliever misuse were associated with less frequent cannabis use. Past-year stimulant use and using cannabis alone were associated with more frequent cannabis use. These findings suggest that additional marginalized identities may increase the risk for maladaptive substance use. Future research should examine substance use behaviors and correlates to inform interventions among this population.

Recruiting Sexual and Gender Minority Veterans for Health Disparities Research: Recruitment Protocol of a Web-Based Prospective Cohort Study

BACKGROUND

The Health for Every Veteran Study is the first Veterans Health Administration-funded, nationwide study on lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) veterans' health that relies exclusively on primary recruitment methods. This study aimed to recruit 1600 veterans with diverse sexual and gender identities to study the mental health and health risk behaviors of this population. A growing body of literature highlights the health inequities faced by LGBTQ+ veterans when compared with their heterosexual or cisgender peer groups. However, there is little to no guidance in the health disparities literature describing the recruitment of LGBTQ+ veterans.

OBJECTIVE

This paper provides an overview of the recruitment methodology of Health for Every Veteran Study. We describe the demographics of the enrolled cohort, challenges faced during recruitment, and considerations for recruiting LGBTQ+ veterans for health research.

METHODS

Recruitment for this study was conducted for 15 months, from September 2019 to December 2020, with the goal of enrolling 1600 veterans evenly split among 8 sexual orientation and gender identity subgroups: cisgender heterosexual women, cisgender lesbian women, cisgender bisexual women, cisgender heterosexual men, cisgender gay men, cisgender bisexual men, transgender women, and transgender men. Three primary recruitment methods were used: social media advertising predominantly through Facebook ads, outreach to community organizations serving veterans and LGBTQ+ individuals across the United States, and contracting with a research recruitment company, Trialfacts.

RESULTS

Of the 3535 participants screened, 1819 participants met the eligibility criteria, and 1062 completed the baseline survey to enroll. At baseline, 25.24% (268/1062) were recruited from Facebook ads, 40.49% (430/1062) from community outreach, and 34.27% (364/1062) from Trialfacts. Most subgroups neared the target enrollment goals, except for cisgender bisexual men, women, and transgender men. An exploratory group of nonbinary and genderqueer veterans and veterans with diverse gender identities was included in the study.

CONCLUSIONS

All recruitment methods contributed to significant portions of the enrolled cohort, suggesting that a multipronged approach was a critical and successful strategy in our study of LGBTQ+ veterans. We discuss the strengths and challenges of all recruitment methods, including factors impacting recruitment such as the COVID-19 pandemic, negative comments on Facebook ads, congressional budget delays, and high-volume surges of heterosexual participants from community outreach. In addition, our subgroup stratification offers important disaggregated insights into the recruitment of specific LGBTQ+ subgroups. Finally, the web-based methodology offers important perspectives not only for reaching veterans outside of the Veterans Health Administration but also for research studies taking place in the COVID-19-impacted world. Overall, this study outlines useful recruitment methodologies and lessons learned to inform future research that seeks to recruit marginalized communities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43824.

Factors Associated with Time to Receiving Gender-Affirming Hormones and Puberty Blockers at a Pediatric Clinic Serving Transgender and Nonbinary Youth

Purpose

To describe barriers to care for a cohort of transgender and nonbinary (TNB) youth and examine factors associated with delays in receiving puberty blockers (PBs) or gender-affirming hormones (GAHs).

Methods

We used longitudinal data from a prospective cohort of TNB youth seeking care at a multidisciplinary pediatric gender clinic between August 2017 and June 2018. We calculated the time between (i) initial clinic contact, (ii) phone intake, (iii) first medical appointment, and (iv) initiating PBs/GAHs. We estimated Kaplan-Meier curves for each time-to-care interval and used Cox regression models to estimate hazard ratios (HRs) for factors hypothesized to be barriers and facilitators of care.

Results

Our cohort included 104 youth aged 13-20 years. The median time from contacting the clinic to initiating PBs/GAHs was 307 days (range, 54-807). Lower income level, Medicaid insurance, and lack of family support were associated with longer times from contacting the clinic to completing the first medical appointment. In addition, older youth experienced longer times to first medical appointment relative to youth aged 13-14 years. Youth younger than 18 years of age who did not complete a mental health assessment before their first medical appointment experienced delays from first medical appointment to initiating PBs/GAHs (HR=0.44, 95% confidence interval, 0.22-0.88).

Conclusion

Certain subsets of youth disproportionately experienced delays in receiving gender-affirming medications, and these factors varied by stage of care engagement. Given the association between gender-affirming care and improved mental health, identifying sociostructural and clinic-level barriers to care is critically important to facilitating more equitable access.

Socioeconomic inequality, health inequity and well-being of transgender people during the COVID-19 pandemic in Nigeria

BACKGROUND

We aimed to explore socioeconomic inequality, health inequity, and the well-being of transgender people during the COVID-19 crisis in Nigeria.

METHODS

Between June and December 2021, a cross-sectional survey was conducted collaboratively with community-based organisations in Nigeria. Participants living with or at risk of HIV were recruited voluntarily, online and face-to-face, using a combination of venue-based and snowball sampling. We assessed the association between gender identity (transgender and vulnerable cisgender women), and (i) socioeconomic inequality measured with socioeconomic status, social status, economic vulnerability, macrosocial vulnerability; (ii) health inequity measured with self-assessment of health, recency of HIV test, access to HIV and sexual and reproductive health services, gender-affirming care, financial and non-financial barriers to accessing health services; and (iii) well-being, measured with gender-based violence, mental health, psychoeconomic preferences. We used multivariable logistic regressions and controlled for interactions and confounders.

RESULTS

There were 4072 participants; 62% were under 30, and 47% reported living with HIV. One in ten (11.9%; n = 485) was transgender, and 56.5% reported living with HIV. Compared to vulnerable cisgender women, the results showed significantly higher odds (aOR:3.80) of disruption in accessing HIV services in transgender participants; gender-based violence (aOR:2.63); severe (aOR:2.28) symptoms of anxiety and depression. Among the barriers to accessing health and HIV services, transgender had three-time higher odds of reporting additional non-official fees compared to vulnerable cisgender women. The disclosure of their gender identity or sexual orientation was the most important non-financial barrier to accessing health services (aOR:3.16). Transgender participants faced higher housing insecurity (aOR: 1.35) and lower odds of using drugs (aOR:0.48). Importantly, they are more likely to have performed a recent HIV test and less likely to not know their HIV status (aOR:0.38) compared to vulnerable cisgender women.

CONCLUSIONS

Socioeconomic inequality, health and well-being inequity in transgender people appear to be exacerbated by the COVID-19 pandemic in Nigeria. Interventions are necessary to mitigate socioeconomic challenges, address structural inequality, and ensure equitable access to health services to meet the Sustainable Development Goals for transgender people.

Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care-A Qualitative Exploration

When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (n_codes = 546), patient-staff dynamics (n_codes = 480), inadequate information and support (n_codes = 210), and lack of autonomy in decision making (n_codes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.

A scoping review of the research literature on eating and body image for transgender and nonbinary adults

BACKGROUND

Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.

AIMS

This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.

RESULTS

After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.

CONCLUSIONS

Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program

Importance

Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation.

Objective

To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people.

Design, Setting, and Participants

This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility.

Exposures

Self-identified gender identity and sexual orientation group.

Main Outcomes and Measures

Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group.

Results

The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups.

Conclusions and Relevance

In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

Healthy and Equitable Interpersonal Relationships, Health Inequalities and Socio-Educational Interventions: A Conceptual Framework for Action

BACKGROUND

Interpersonal relationships undoubtedly have a bidirectional connection with the health of individuals and communities. Relational models based on equity contribute to well-being, while asymmetrical relationships based on hierarchies and differences of power negatively impact mental, physical, and social health.

METHODS

A conceptual framework for understanding the determinants of interpersonal relational models was developed.

RESULTS

Structural determinants were identified as the combined action of systems of oppression, the socio-historical context that normalizes violence, and social stratification and segregation, consequences which included inequitable access to power, resources, and opportunities. Intermediate determinants include individual, psychosocial, behavioral, and community aspects. Structural and intermediate determinants impact health and health inequalities through multiple relational patterns that are simultaneously established and sustained by individuals and communities. The health impact of inequitable relational patterns includes: Reduced self-esteem; anxiety, stress, and depression; acceptance of violence; physical and sexual harm; suicide; and murder.

CONCLUSIONS

This conceptual framework allows for the modification of relational models by influencing structural and intermediate determinants. Six areas of intervention have been identified: educative policies, school governance, physical and symbolic space, school curriculum, school-community relations, and socio-educative interventions to promote healthy and equitable relationships. Healthy and equitable relationships are associated with improved subjective well-being, health status and protection from violence. Socio-educational interventions that consider the elements of this conceptual framework may be effective in promoting healthy and equitable relational models.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Structural vulnerability as a conceptual framework for transgender health research: findings from a community needs assessment of transgender women of colour in Detroit

The concept of structural vulnerability explains how systems of oppression drive health inequities by reducing access to survival resources (e.g. food, housing) for marginalised populations. Indicators of structural vulnerability such as housing instability, violent victimisation and poverty are often interconnected and result from intersectional oppression. We sought to demonstrate the utility of the structural vulnerability framework for transgender health research by examining patterns of structural vulnerability indicators among transgender women of colour in Detroit. We conducted latent class analysis and tested associations between classes and mental health and substance use outcomes. Membership to the Lowest Vulnerability class was negatively associated with post-traumatic stress disorder (PTSD) (aOR = 0.10, 95% CI: 0.02-0.59). High Economic Vulnerability membership was associated with daily marijuana use (aOR = 4.61, 95% CI: 1.31-16.16). Complex Multi-Vulnerability membership was associated with PTSD (aOR = 9.75, 95% CI: 2.55-37.29), anxiety (aOR = 4.12, 95% CI: 1.22-13.97), suicidality (aOR = 6.20, 95% CI: 1.39-27.70), and club drug use (aOR = 4.75, 95% CI: 1.31-17.29). Substantively different findings emerged when testing relationships between each indicator and each outcome, highlighting the value of theoretically grounded quantitative approaches to understanding health inequities. Community-driven interventions and policy changes that reduce structural vulnerability may improve mental health and substance use outcomes among structurally vulnerable trans women of colour.

Transgender Adults From Minoritized Ethnoracial Groups in the U.S. Report Greater Subjective Cognitive Decline

OBJECTIVES

Investigate subjective cognitive decline (SCD) among 4 study groups consisting of cisgender and transgender adults who are from minoritized ethnoracial groups (i.e., minoritized ethnoracial transgender, minoritized ethnoracial cisgender) and White cisgender and transgender adults aged 45+ (i.e., White transgender, White cisgender) to determine the odds of SCD by group and to test for group differences.

METHODS

Data from the 2015-2020 Behavioral Risk Factor Surveillance System were used in a modified case-control approach to perform an intercategorical intersectional study. Each transgender participant was matched to 2 cisgender men and 2 cisgender women, on state, ethnoracial identity, and age. Multivariable logistic regressions modeled SCD odds by group and post hoc contrasts estimated pairwise odds ratios comparing the SCD odds for each combination of groups.

RESULTS

SCD prevalence was highest among minoritized ethnoracial transgender (21.6%), followed by White transgender (15.0%), minoritized ethnoracial cisgender (12.0%), and White cisgender (9.0%). After accounting for age, education, and survey year, the odds of SCD were higher in minoritized ethnoracial transgender when compared to White cisgender (adjusted odds ratio [aOR] = 2.51, 95% confidence interval [CI]: 1.59-3.96) and minoritized ethnoracial cisgender (aOR = 1.89, 95% CI: 1.16-3.09). The odds of SCD were higher in White transgender compared to White cisgender (aOR = 1.66, 95% CI: 1.20-2.30).

DISCUSSION

When considering the intersection of transgender and ethnoracial identities, we found that transgender adults from minoritized ethnoracial groups reported higher odds of SCD when compared to cisgender adults from minoritized ethnoracial groups. Additional studies are needed to understand the relationship between racialized and gendered inequities in cognitive impairment and how specific mechanisms of systemic transphobia and racism may contribute to this inequity.

An Implementation of a Community-Engaged, Group-Level Mental Health Pilot for Black and Latina Transgender Women

The primary aim is to assess the implementation of an eight-session, group therapy pilot for Black and Latina transgender women in Chicago in terms of implementation outcomes regarding intervention effectiveness, acceptability, appropriateness, and feasibility. The Exploration Preparation Implementation Sustainment (EPIS) framework guided implementation processes, including community engagement as an implementation strategy, and an implementation taxonomy was used to evaluate outcomes of acceptability, appropriateness, and feasibility, in addition to intervention effectiveness regarding anxiety and community connectedness. Two rounds of the pilot were completed in 2020, during the COVID-19 pandemic, at a community-based organization serving LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) youth on Chicago's West Side. Participants (N = 14) completed a baseline and postintervention assessment and evaluations after each of eight intervention modules. Descriptive statistics show improvement across measures of anxiety and community connectedness, and high mean scores across domains of acceptability, appropriateness, and feasibility. Pilot findings indicate intervention effectiveness, acceptability, appropriateness, and feasibility to address mental health and social support of Black and Latina transgender women. Additional resources are needed for transgender community-engaged mental health programs and research to establish core and adaptable intervention elements, scaled-up evidence for clinical effectiveness, and, most importantly, to improve mental health outcomes and the sustainability of such interventions.

Community-Led Response to Address Economic Vulnerability due to COVID-19 with, for, and by Transgender Women of Color: A Qualitative Pilot Evaluation

Purpose

Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color.

Methods

We conducted a pilot program evaluation (n=8).

Results

Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as "somewhat to extremely easy." Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities.

Conclusion

Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color.

Stressors in health care and their association to symptoms experienced by gender diverse people

OBJECTIVES

Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people.

STUDY DESIGN

This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey.

METHODS

Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims.

RESULTS

A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (β = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants.

CONCLUSIONS

The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms.

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

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

Community Engagement in Research and Design of a Transgender Health Information Resource

BACKGROUND

 Access to credible and relevant health care information is an unmet need for the transgender and gender-diverse (TGD) community. This paper describes the community engagement methods and resulting community priorities as part of a codesign process for the development of a Transgender Health Information Resource (TGHIR) application.

METHODS

 A lesbian, gay, bisexual, transgender, and queer advocacy organization and an academic health sciences team partnered to establish a community advisory board (CAB) of TGD individuals, parents of TGD individuals, and clinicians with expertise in transgender health to inform the project. The analytic-deliberative model and group facilitation strategies based on Liberating Structures guided procedures. Affinity grouping was used to synthesize insights from CAB meeting notes regarding roles and perspectives on the design of the TGHIR application. We used the Patient Engagement in Research Scale (PEIRS) to evaluate CAB members' experience with the project.

RESULTS

 The CAB emphasized the importance of designing the application with and for the TGD community, including prioritizing intersectionality and diversity. CAB engagement processes benefited from setting clear expectations, staying focused on goals, synchronous and asynchronous work, and appreciating CAB member expertise. TGHIR application scope and priorities included a single source to access relevant, credible health information, the ability to use the app discreetly, and preserving privacy (i.e., safe use). An out-of-scope CAB need was the ability to identify both culturally and clinically competent TGD health care providers. PEIRS results showed CAB members experienced moderate to high levels of meaningful engagement (M[standard deviation] = 84.7[12] out of 100).

CONCLUSION

 A CAB model was useful for informing TGHIR application priority features. In-person and virtual methods were useful for engagement. The CAB continues to be engaged in application development, dissemination, and evaluation. The TGHIR application may complement, but will not replace, the need for both culturally and clinically competent health care for TGD people.

Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study

BACKGROUND

The 21st Century Cures Act and the OpenNotes movement have brought patients immediate access to their electronic health records (EHRs). The experiences of marginalized people, including transgender people, accessing and reviewing their EHRs could inform documentation guidelines to improve patient-clinician rapport and reduce harm.

OBJECTIVE

To investigate the experiences of transgender people reviewing EHRs.

DESIGN

Qualitative study using community-engaged research and an interpretive description methodology. Participants were recruited via social media, snowball sampling was employed, and purposive sampling was used to ensure diversity in terms of age, race/ethnicity, and other factors. In focus groups, participants were asked to discuss their experiences reviewing their EHRs and, for those participants who were clinicians, their experiences reviewing other clinicians' documentation.

PARTICIPANTS

Thirty transgender adults aged 20 to 67 years, including 10 clinicians.

APPROACH

Digital audio-recordings of focus groups were transcribed verbatim. Content was analyzed to identify emerging essential elements and analysis was continued until no new themes emerged (i.e., saturation).

KEY RESULTS

Four themes were noted. (1) Using the wrong name, pronoun, or gender marker for patients is common in the EHR, erodes trust, and causes trauma. (2) Various aspects of clinicians' notes contradict, blame, or stigmatize patients, across multiple axes of oppression. (3) Limitations of EHR capabilities create barriers to quality care. (4) Certain medical customs set the stage for marginalizing, objectifying, and pathologizing transgender people.

CONCLUSIONS

Transgender people experience harm via various aspects of EHR documentation, suggesting that changes must be made to improve patient-clinician relationships and reduce ill-effects for patients.