Female-to-male transmasculine adult health: a mixed-methods community-based needs assessment

The Effect of Minority Stress Processes on Smoking for Lesbian, Gay, Bisexual, Transgender, and Queer Individuals: A Systematic Review

Purpose: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals are more likely to smoke than non-LGBTQ individuals. Smoking has been posited as a coping mechanism for LGBTQ individuals facing minority stress. However, the exact relationship between minority stress and smoking behaviors among LGBTQ individuals is unclear. Therefore, the purpose of this systematic review was to examine how minority stress processes are associated with smoking behaviors for LGBTQ individuals. Methods: Searches of the PubMed and PsycINFO databases were conducted for smoking-, LGBTQ-, and minority stress-related terms. No date, geographic, or language limits were used. For inclusion, the study must have (1) been written in English, (2) had an LGBTQ group as the study population or a component of the study population, (3) assessed the cigarette smoking status of patients, and (4) assessed at least one minority stress-related process (internalized stigma, perceived stigma, or prejudice events). Results: The final review included 44 articles. Aside from two outlier studies, all of the reviewed studies exhibited that increased levels of minority stress processes (internalized queerphobia, perceived stigma, and prejudice events) were associated with increased probability of cigarette use in LGBTQ individuals. Increased minority stress was also associated with greater psychological distress/mental health decline. Conclusion: The findings of this review suggest that minority stress processes represent a contributing factor to smoking health disparities in LGBTQ populations. These results highlight the need for smoking cessation and prevention programs to address minority stress and improve smoking disparities in these populations.

L’approche syndémique appliquée à la santé des minorités sexuelles et de genre : étude de la portée

INTRODUCTION

Sexual and gender minorities (SGM) represent a vulnerable population, disproportionately affected by mental health issues, a higher exposure to violence and a higher prevalence of sexually transmitted infections, including HIV, for some subgroups. Derived from medical anthropology, the concept of a syndemic consists in the clustering and interaction between multiple health conditions through adverse social conditions such as discrimination or precarity. Confronted to the multitude of adverse conditions affecting SGM, this framework is pertinent to study their health and to propose interventions.

PURPOSE OF RESEARCH

The purpose of this scoping review is to synthetize the knowledge regarding syndemic theory applied to sexual and gender minorities in order to propose concrete suggestions for scholarly research and field intervention.

RESULTS

126 papers were included. European data as well as data concerning sexual minority women and transgender men are scarce. A co-occurrence of psychosocial conditions fostered by stigmatization is well-established. Furthermore, the presence of a syndemic was associated to sexual higher odds of acquiring HIV, suicidal behavior and healthcare utilization.

CONCLUSIONS

The syndemic framework is important to the health of SGM, both for academic and interventional purposes. Current priorities should be to act against structural disadvantages leading to a syndemic, to improve our knowledge on SGM health in European context and to develop local programs based on peer-support.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

Social Media as a Recruitment Strategy with Transgender-Identified Individuals: Using an Ethical Lens to Direct Methodology

Introduction: Researchers are limited when using traditional recruitment methods to access hidden and vulnerable populations, including transgender persons. Social media platforms such as Facebook can provide access to the transgender population and facilitate recruitment of a representative sample. There is little regulatory guidance for using social media as a recruitment strategy. Methodology: This article presents recruitment recommendations based on a study that generated a diverse sample of transgender-identified persons using Facebook as the sole recruitment method. Results: Despite taking precautions, computer bots penetrated the initial survey. A second survey distribution collected data from a diverse sample of transgender-identified individuals. Discussion: Researchers should design social media recruitment methods with attention to privacy and transparency. Thus, using social media platforms such as Facebook to recruit transgender participants that otherwise would be challenging to reach is a viable and ethically sound alternative to traditional recruitment methods.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

The 2016 United States presidential election's impact on families with transgender adolescents in New England

During and after the 2016 United States (U.S.) presidential election, discriminatory policies and stigmatizing rhetoric have been increasingly directed toward the transgender community at state and national levels. Transgender and/or nonbinary (TNB) adolescents, already at elevated risk for poorer health relative to their cisgender (nontransgender) peers, may have been adversely impacted by the shifting sociopolitical climate. This secondary analysis used qualitative data from the Trans Teen and Family Narratives Project to investigate how perceived shifts in the sociopolitical climate following the 2016 election affected families with TNB adolescents in the New England region of the U.S. (states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). Data included two waves of semistructured interviews conducted with TNB adolescents and their caregivers and siblings (N = 20 families, 60 family members). Two coders analyzed transcripts using a thematic analysis approach. Emergent themes included: contemporary life for trans people in America (e.g., being discriminated against and dehumanized), perceptions of the national sociopolitical climate (e.g., anger toward political figures), forms of resistance and advocacy (e.g., confronting misinformation), and factors amplifying or buffering effects of the sociopolitical climate (e.g., the formation of alliances or coalitions within the family). Findings indicate the 2016 election spurred the redefinition of communication boundaries within, and outside, the immediate family, particularly regarding online communication and social media. TNB adolescents and their families anxiously anticipated changes in the sociopolitical climate and their foreseen impact on TNB adolescents' rights and safety. Implications for family therapy, intervention design, and policy reform are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review

IMPORTANCE

Transgender and nonbinary youths have a higher incidence of a range of health conditions and may paradoxically face limited access to health care.

OBJECTIVE

To describe the perspectives and needs of transgender youths in accessing health care.

EVIDENCE REVIEW

MEDLINE, Embase, PsycInfo, and the Cumulative Index to Nursing and Allied Health Literature were searched from inception to January 2021. Qualitative studies of transgender youths' perspectives on accessing health care were selected. Results from primary studies were extracted. Data were analyzed using thematic synthesis.

FINDINGS

Ninety-one studies involving 884 participants aged 9 to 24 years across 17 countries were included. We identified 6 themes: experiencing pervasive stigma and discrimination in health care, feeling vulnerable and uncertain in decision-making, traversing risks to overcome systemic barriers to transitioning, internalizing intense fear of consequences, experiencing prejudice undermining help-seeking efforts, and experiencing strengthened gender identity and finding allies. Each theme encapsulated multiple subthemes.

CONCLUSIONS AND RELEVANCE

This review found that transgender youths contend with feelings of gender incongruence, fear, and vulnerability in accessing health care, which are compounded by legal, economic, and social barriers. This can lead to disengagement from care and resorting to high-risk and unsafe interventions. Improving access to gender-affirming care services with a cultural humility lens and addressing sociolegal stressors may improve outcomes in transgender and nonbinary youths.

Using a Comprehensive Proximal Stress Model to Predict Alcohol Use

Purpose: The gender minority stress model has been proposed by researchers to explain the high rates of substance use found within transgender communities, but its explanatory power has never been directly tested. Further, qualitative research has noted that premedically transitioned and nonbinary individuals are more likely to engage in avoidant coping such as drinking to cope. As such, the current study tested the relationship between proximal stress (comprised of internalized transphobia, anticipated stigma, concealment, and gender dysphoria), drinking to cope, and problematic alcohol use. Methods: Transgender and nonbinary participants over the age of 18 (N=297) completed an online survey on alcohol use. To test for differences in drinking to cope across gender identity and medical transition, analysis of variance and independent t-tests were conducted. Further, a structural equation model of proximal stress was developed to test whether drinking to cope mediated the relationship between proximal stress and alcohol use. Results: There were no significant differences across gender identity or medical transition status in severity of drinking to cope. Proximal stress was significantly related to problematic alcohol use and the relationship was explained by an indirect relationship with drinking to cope. Conclusion: Findings from this study suggest that drinking to cope is an important aspect of high rates of alcohol use found in the transgender community. Implications for clinical practice with transgender individuals are discussed.

Addendum to: Development and Validation of a Scale to Measure Intimate Partner Violence Among Transgender and Gender Diverse Populations: Protocol for a Linear Three-Phase Study (Project Empower)

[This corrects the article DOI: 10.2196/23819.].

Trans and gender diverse people's experiences of healthcare access in Australia: A qualitative study in people with complex needs

Introduction

This study aimed to explore the experiences of healthcare access in a diverse sample of trans and gender diverse individuals with complex needs using qualitative methods. We recruited 12 individuals using trans community-based networks facilitated by the Gender Centre. Each individual participated in an in-depth, semi structured interview conducted by a peer interviewer. Interviews were analysed thematically.

Findings

Participants had a range of complex health needs to manage, including ongoing access to gender-affirming hormones, mental health care and sexual health care. Some also had chronic diseases. Accordingly, scheduling appointments and affording the co-payments required were major preoccupations. Most participants were not in full time work, and economic hardship proved to be a major compounding factor in issues of healthcare access, impacting on the choice of clinician or practice. Other barriers to accessing health included issues within health services, such as disrespectful attitudes, misgendering, ‘deadnaming’ (calling the person by their previous name), displaying an excessive interest is aspects of the participants’ life that were irrelevant to the consultation, and displaying ignorance of trans services such that the participants felt an obligation to educate them. In addition, participants noted how stereotyped ideas of trans people could result in inaccurate assumptions about their healthcare needs. Positive attributes of services were identified as respectful communication styles, clean, welcoming spaces, and signs that indicated professionalism, care and openness, such as relevant information pamphlets and visibility of LGBTIQ service orientation. Participants valued peer-based advice very highly, and some would act on and trust medical advice from peers above advice from medical professionals.

Conclusion

These findings demonstrate a need for comprehensive wrap-around service provision for trans people with complex needs which includes a substantial peer-based component, and addresses physical and mental health and social services conveniently and affordably.

"I Use All the Parts I'm Given": A Qualitative Investigation of Trans Masculine and Nonbinary Individuals' Use of Body during Sex

Objectives: The study investigates how trans masculine and nonbinary individuals describe the use of their bodies during sexual activities. Methods: Three hundred and sixty-one trans masculine and nonbinary individuals were asked to describe their use of body during sex through an online survey. Data were analyzed through thematic analysis. Results: Eleven subthemes emerged that were organized in 4 overarching themes: Relational Factors; Behavioral Factors; Sexual Roles; and Transgender Related Factors. Some differences emerged between trans masculine and nonbinary participants. Conclusions: Although some of our participants described a lack of sexual activity, our participants overall described a wide range of activities.

Prevalence and correlates of substance use among transgender adults: A systematic review

INTRODUCTION

Minority stress theories suggest that high rates of discrimination experienced by transgender people are precipitants of substance use. This risk is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which transgender status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

METHODS

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, Embase and Global Health databases. Primary quantitative studies, published in English, that reported the prevalence, patterns or correlates of substance use by transgender people were included, with no restriction on methodological design.

RESULTS

653 unique records were identified, and 41 studies were included. Half the studies reported on both transgender men and transgender women and half transgender women only. There was high and excess prevalence of substance use among transgender compared with cisgender people, but insufficient evidence to estimate prevalence or quantify the risk for substance use. Correlates of substance use included transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

CONCLUSIONS

The sparse findings lend support to the minority stress model. However, the overreliance of the literature on disproportionate investigation of transgender women with multiple intersectional disadvantages, means there are significant gaps regarding the wider transgender community. To ensure substance use treatment services are inclusive, gender identity should be recorded and targeted interventions available. Clinicians should be aware of the multiple, complex drivers of substance use and be prepared to ask about substance use and offer support. Given the high prevalence of trauma experienced by transgender people, trauma-informed psychosocial interventions may be useful in the management of problematic substance use in transgender adults.

Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis

Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.

Development and Validation of a Scale to Measure Intimate Partner Violence Among Transgender and Gender Diverse Populations: Protocol for a Linear Three-Phase Study (Project Empower)

BACKGROUND

Intimate partner violence (IPV) is approximately twice as prevalent among transgender and gender diverse individuals (those whose current gender identity does not match their sex assigned at birth) than among cisgender individuals (those whose gender aligns with their sex assigned at birth). However, most existing scales measuring IPV are not validated among transgender and gender diverse populations and do not consider the unique forms of IPV experienced by transgender and gender diverse individuals.

OBJECTIVE

This paper describes the protocol for Project Empower, a study that seeks to develop and validate a new scale to measure IPV as experienced by transgender and gender diverse adults. A new scale is necessary to improve the accuracy of IPV measurement among transgender and gender diverse populations and may inform the current tools used to screen and link to services for transgender and gender diverse people who experience or perpetrate IPV.

METHODS

The proposed new scale will be developed by a linear three-phase process. In Phase I, we will recruit a maximum of 110 transgender and gender diverse participants to participate in in-depth interviews and focus groups. Phase I will collect qualitative data on the experiences of IPV among transgender and gender individuals. After generating scale items from the qualitative data in Phase I, Phase II will conduct up to 10 cognitive interviews to examine understanding of scale items and refine wording. Phase III will then conduct a survey with an online recruited sample of 700 transgender and gender diverse individuals to validate the scale using factor analysis and examine the prevalence, antecedents, and linked health outcomes of IPV. This study will generate the first comprehensive IPV scale including trans-specific IPV tactics that has undergone robust mixed-methods validation for use in transgender and gender diverse populations, regardless of sex assigned at birth.

RESULTS

Project Empower launched in August 2019, with Phases I and II expected to be complete by late 2020. Phase III (survey of 700 transgender individuals) is expected to be launched in January 2021.

CONCLUSIONS

A scale that more accurately captures the forms of IPV experienced by transgender and gender diverse people not only has the potential to lead to more accurate measurements of prevalence but also can identify unique forms of violence that may form the basis of IPV prevention interventions. Additionally, identifying the forms of IPV experienced by transgender and gender diverse people has the potential to lead to the refinement of clinical screening tools used to identify and refer those who experience and perpetrate violence in clinical settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23819.

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.

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.

Qualitative socioecological factors of cervical cancer screening use among transgender men

•

Attendance to cervical cancer screening is related to gender identity development.

•

Provider attitudes are critical to improving cancer screening for transgender men.

•

Healthcare public physical spaces can promote cancer screening for transgender men.

Lack of attendance to cervical cancer screening (CCS) services is the most attributable factor to the development of cervical cancer. Transgender men, individuals whose gender identity does match with their natal female sex, use CCS less often than the general female population. The underlying reasons for deficient CCS among transgender men relate mostly to their stigmatized identity, such as discrimination and unwelcoming healthcare environments. However, additional research is needed to expand our understanding of this complex issue. This exploratory qualitative research study aimed to identify the determinants of CCS from the perspective of transgender men. Twenty transgender men ages 21–65 were conveniently sampled to participate in a semi-structured interview in 2018. The data were analyzed using a deductive-inductive content analysis approach and the results were sorted into a socioecological framework (SEM). The participants were mostly non-Hispanic and white. The mean age was 33, and 55% of the sample had attended CCS in the last three years. Eight overarching factors were identified in the data. Each factor included descriptive sub-factors. At the institutional and interpersonal SEM levels, factors related to healthcare providers and healthcare organizations. At the individual level, factors related to past negative experiences, gender identity development, and socioeconomic status. To the investigators’ knowledge, this is the first study to report the relationship between gender identity development and CCS behaviors. Gender identity development refers to the transition or coming-out process and gender dysphoria. This suggests that attendance to CCS services change as a transgender person’s identity evolves.

Development of a Natural Language Processing Algorithm to Identify and Evaluate Transgender Patients in Electronic Health Record Systems

Objective

To create a natural language processing (NLP) algorithm to identify transgender patients in electronic health records.

Design

We developed an NLP algorithm to identify patients (keyword + billing codes). Patients were manually reviewed, and their health care services categorized by billing code.

Setting

Vanderbilt University Medical Center.

Participants

234 adult and pediatric transgender patients.

Main Outcome Measures

Number of transgender patients correctly identified and categorization of health services utilized.

Results

We identified 234 transgender patients of whom 50% had a diagnosed mental health condition, 14% were living with HIV, and 7% had diabetes. Largely driven by hormone use, nearly half of patients attended the Endocrinology/Diabetes/Metabolism clinic. Many patients also attended the Psychiatry, HIV, and/or Obstetrics/Gynecology clinics. The false positive rate of our algorithm was 3%.

Conclusions

Our novel algorithm correctly identified transgender patients and provided important insights into health care utilization among this marginalized population.

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.

The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health

PURPOSE

Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition.

METHODS

Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma.

RESULTS

Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status.

CONCLUSION

In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.

Motivators and Barriers to Accessing Sexual Health Care Services for Transgender/Genderqueer Individuals Assigned Female Sex at Birth

Purpose: Individuals who were assigned female sex at birth (AFAB) but do not conform to the gender binary (i.e., transgender/genderqueer) often do not seek out necessary sexual health care, including Papanicolaou (Pap) tests, placing them at heightened risk of cervical cancer. Despite growing awareness, scant research has focused on the sexual health care experiences of this population in Midwestern and rural states.

Methods: We used two approaches to develop a more detailed understanding of factors that determine sexual health care use. Seventeen transgender/genderqueer AFAB individuals completed a quantitative knowledge survey then participated in a semistructured qualitative interview to further elaborate their experiences with sexual health care services as well as the motivators and barriers related to accessing the health care system. We produced descriptive summaries of quantitative data and conducted a thematic analysis of interview transcripts.

Results: The sample was mostly young adults, of whom nearly all were white and 65% self-identified as transgender men. Participants displayed good knowledge about human papillomavirus (HPV) and Pap tests; however, 41% rated themselves as “unaware” and 59% rated themselves as “aware but not well informed” about HPV. Fifty-nine percent had ever obtained a Pap test. We identified one facilitating factor (health care provider's role and relationship) and three inhibiting factors (availability of competent care; distress about seeking sexual health care; health care setting characteristics) related to obtaining Pap tests.

Conclusion: As this study was conducted in the U.S. Midwest, findings extend the geographic scope of existing knowledge and may inform future risk reduction interventions and clinical practice.

"In a Perfect World, You Wouldn't Have to Work the System to Get the Things You Need to Survive": A Pilot Study About Trans Health Care Possibilities

Purpose: aTHeNA (a Trans Health Needs Assessment) is a pilot study exploring the perspectives and experiences of trans people in western Massachusetts on and with health care. This study examines research strategies and best practices to improve trans health care by prioritizing the knowledge and recommendations of trans and gender nonbinary people.

Methods: aTHeNA is composed of a focus group of eight trans and gender nonbinary individuals held in western Massachusetts in January of 2016 and qualitative analysis of that focus group to synthesize themes. aTHeNA utilized an interdisciplinary approach. Concepts of respect, care, self-definition, and intersectionality informed study design and analysis.

Results: Key participant recommendations include providing medical care that recognizes and values client self-knowledge, elimination of gender markers in insurance billing, and comprehensive health care team education across inpatient and outpatient settings.

Conclusion: Focus group participants outlined the limitations of current services and envisioned possibilities for a more ideal system. Further research is needed to incorporate trans perspectives into health literature.

Nursing Care for the transgender population: genders from the perspective of professional practice

ABSTRACT Objective: To describe and analyze the national and international scientific production on Nursing care for the transgender or gender-variance population. Method: Integrative review of the literature, conducted throughout the Virtual Health Library, Cumulative Index to Nursing and Allied Health Literature, Public Medline and Web of Science databases, without pre-established periods of time and using the descriptors "Transgender AND ‘Nursing Assistance'" and "Transgender AND ‘Nursing care'". Results: We included 11 articles, published between 2005 and 2016, broadly North American with only one Brazilian, so categorized: I- Fragility in the care of transgender people; II - Health of the transgender population: general and specific demands; III- Public health policies for transgender people. Transgender people have not found yet answers to their health demands; they are victims of prejudices and violence in services and seek care in extreme cases of sickness. Final considerations: Understanding their needs is primordial to build knowledge and practices that support nursing care.

Chest Binding and Care Seeking Among Transmasculine Adults: A Cross-Sectional Study

Purpose: Chest binding, or compressing the chest tissue, is a common practice among transmasculine individuals that can promote mental health, but frequently results in negative physical health symptoms. The purpose of this study was to assess the prevalence and correlates of care seeking for binding-related health concerns among transmasculine adults.

Methods: Descriptive statistics were calculated and logistic regression models were run using data from the Binding Health Project, a cross-sectional online survey among transgender adults who had practiced chest binding (n=1800). The analysis was restricted to transmasculine individuals who had consistent access to health care and were female assigned at birth or intersex (n=1273).

Results: Of 1273 participants, 88.9% had experienced at least one binding-related symptom and 82.3% believed that it was important to discuss chest binding with their health care provider, while 14.8% had sought care related to binding. Participants reporting pain, musculoskeletal, or neurological symptoms had 3.19, 1.85, and 1.72 times the adjusted odds, respectively, of seeking care compared to those who did not report those symptoms (95% confidence intervals [CIs]: 1.38–7.37; 1.12–3.06; 1.10–2.68). Care seeking was associated with feeling safe and comfortable initiating a conversation about binding with one's provider (adjusted odds ratio [AOR]=2.07, 95% CI 1.32–3.24). Care seeking was not significantly associated with feeling comfortable receiving a chest examination (AOR=1.07, 95% CI 0.71–1.62).

Conclusion: Low rates of care seeking for binding-related symptoms may be driven by lack of access to a provider with whom patients feel safe and comfortable, rather than by general discomfort with chest examinations. While transmasculine patients may be most likely to present with musculoskeletal, neurological, or pain-related concerns, providers should also assess for other symptoms. Providers should be familiar with the benefits and potential complications of binding and initiate non-stigmatizing positive discussions about binding with their transmasculine patients.

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

BACKGROUND

Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

OBJECTIVE

To examine the incidence of these events in a cohort of transgender persons.

DESIGN

Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

SETTING

Kaiser Permanente in Georgia and northern and southern California.

PATIENTS

2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

MEASUREMENTS

VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

RESULTS

Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

LIMITATION

Inability to determine which transgender members received hormones elsewhere.

CONCLUSION

The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies

BACKGROUND

There is a recent and growing research literature on alcohol use and related harms among transgender and other gender minority populations; however, current definitions and measures of hazardous drinking do not consider the complexity of physiological sex characteristics and socially constructed gender, raising doubts regarding their validity, applicability, and use with these populations. To address this, we reviewed current research on alcohol-related outcomes in transgender populations and critically summarized key issues for consideration in future research.

METHODS

We conducted a systematic review of transgender alcohol research in English language, peer-reviewed journals, published 1990-2017, and extracted key details (e.g., sample composition, alcohol measures, results).

RESULTS

Forty-four studies met all inclusion criteria for the review, the majority of which were conducted in the United States. The prevalence of hazardous drinking was high; however, estimates varied widely across studies. We noted frequent methodological weaknesses, including few attempts to differentiate sex and gender, poor attention to appropriate definitions of hazardous drinking, and reliance on cross-sectional study designs and non-probability sampling methods.

CONCLUSION

Given findings that suggest high need for ongoing public health attention, we offer recommendations to improve future alcohol studies with transgender and other gender minority populations, such as being explicit as to whether and how sex and/or gender are operationalized and relevant for the research question, expanding the repertoire of alcohol measures to include those not contingent on sex or gender, testing the psychometric performance of established screening instruments with transgender populations, and shifting from descriptive to analytic study designs.

Quality of Life in Transitioned Trans Persons: A Retrospective Cross-Sectional Cohort Study

Background

Medical gender-affirming interventions (GAI) are important in the transition process of many trans persons. The aim of this study was to examine the associations between GAI and quality of life (QoL) of transitioned trans individuals.

Methods

143 trans persons were recruited from a multicenter outpatient Swiss population as well as a web-based survey. The QoL was assessed using the Short Form (36) Health Survey questionnaire (SF-36). Depressive symptoms were examined using the Short Form of the Center for Epidemiologic Studies-Depression Scale (ADS-K). Multiple interferential analyses and a regression analysis were performed.

Results

Both transfeminine and transmasculine individuals reported a lower QoL compared to the general population. Within the trans group, nonbinary individuals showed the lowest QoL scores and significantly more depressive symptoms. A detailed analysis identified sociodemographic and transition-specific influencing factors.

Conclusions

Medical GAI are associated with better mental wellbeing but even after successful medical transition, trans people remain a population at risk for low QoL and mental health, and the nonbinary group shows the greatest vulnerability.

Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people

PURPOSE

The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population.

PARTICIPANTS

A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016.

FINDINGS TO DATE

About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers.

FUTURE PLANS

STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to gender affirmation therapy.

Supporting the Health and Well-Being of Transgender Students

Throughout the United States, there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) legislation, including "bathroom bills" that would require transgender people to use public facilities corresponding with the sex designated on their birth certificates. With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? In this article, we aim to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. We will explain transgender identities; transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches in caring for transgender youth; and implications for school nurses. School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive.

A Systematic Review of Interventions to Reduce Problematic Substance Use Among Transgender Individuals: A Call to Action

Persons who are transgender (i.e., individuals who are assigned one sex at birth, but who do not identify with that sex) are at elevated risk for developing problematic substance use. Recent studies indicate that transgender persons have high rates of alcohol use, illicit drug use, and nonmedical use of prescription drugs and evince more severe misuse of these substances compared with nontransgender individuals. Despite the high rates of substance use among transgender persons and the multiple conceptual and narrative recommendations for substance use treatments, there is a lack of consensus or awareness of empirically tested interventions and programs effective for this population. Thus, it is critical to examine current substance use interventions for transgender individuals to identify gaps in the field and to immediately put forth efforts to reduce problematic substance use. This systematic review is the first to attempt a comprehensive identification and synthesis of the available evidence on interventions for reducing problematic substance use among transgender persons. Reflective of the state of the field regarding transgender care for substance use, we found a deficiency of studies to include in this systematic review (n=2). Perhaps the most important conclusion of this review is that well-designed, theoretically informed culturally sensitive research focused on developing and rigorously testing interventions for substance use among transgender individuals is alarmingly scarce. This review discusses barriers to intervention design and synthesizes treatment recommendations for future work.

Documenting research with transgender and gender diverse people: protocol for an evidence map and thematic analysis

BACKGROUND

There is limited information about how transgender, gender diverse, and Two-Spirit (trans) people have been represented and studied by researchers. The objectives of this study are to (1) map and describe trans research in the social sciences, sciences, humanities, health, education, and business, (2) identify evidence gaps and opportunities for more responsible research with trans people, (3) assess the use of text mining for study identification, and (4) increase access to trans research for key stakeholders through the creation of a web-based evidence map.

METHODS

Study design was informed by community consultations and pilot searches. Eligibility criteria were established to include all original research of any design, including trans people or their health information, and published in English in peer-reviewed journals. A complex electronic search strategy based on relevant concepts in 15 databases was developed to obtain a broad range of results linked to transgender, gender diverse, and Two-Spirit individuals and communities. Searches conducted in early 2015 resulted in 25,242 references after removal of duplicates. Based on the number of references, resources, and an objective to capture upwards of 90% of the existing literature, this study is a good candidate for text mining using Latent Dirichlet Allocation to improve efficiency of the screening process. The following information will be collected for evidence mapping: study topic, study design, methods and data sources, recruitment strategies, sample size, sample demographics, researcher name and affiliation, country where research was conducted, funding source, and year of publication.

DISCUSSION

The proposed research incorporates an extensive search strategy, text mining, and evidence map; it therefore has the potential to build on knowledge in several fields. Review results will increase awareness of existing trans research, identify evidence gaps, and inform strategic research prioritization. Publishing the map online will improve access to research for key stakeholders including community members, policy makers, and healthcare providers. This study will also contribute to knowledge in the area of text mining for study identification by providing an example of how semi-automation performs for screening on title and abstract and on full text.

Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study

Chest binding involves the compression of chest tissue for masculine gender expression among people assigned a female sex at birth, particularly transgender and gender non-conforming individuals. There are no peer-reviewed studies that directly assess the health impacts of chest binding, yet transgender community resources commonly discuss symptoms such as pain and scarring. A cross-sectional 32-item survey was administered online to an anonymous, non-random sample of adults who were assigned a female sex at birth and had had experience of binding (n = 1800). Multivariate regression models were used to identify practices associated with self-reported health outcomes. Of participants, 51.5% reported daily binding. Over 97% reported at least one of 28 negative outcomes attributed to binding. Frequency (days/week) was consistently associated with negative outcomes (22/28 outcomes). Compression methods associated with symptoms were commercial binders (20/28), elastic bandages (14/28) and duct tape or plastic wrap (13/28). Larger chest size was primarily associated with dermatological problems. Binding is a frequent activity for many transmasculine individuals, despite associated symptoms. Study findings offer evidence of how binding practices may enhance or reduce risk. Clinicians caring for transmasculine patients should assess binding practices and help patients manage risk.

Cancer in Transgender People: Evidence and Methodological Considerations

Transgender people comprise a diverse group of individuals whose gender identity or expression differs from that originally assigned to them at birth. Some, but not all, transgender people elect to undergo medical gender affirmation, which may include therapy with cross-sex hormones and/or surgical change of the genitalia and other sex characteristics. As cross-sex hormones administered for the purposes of gender affirmation may be delivered at high doses and over a period of decades, the carcinogenicity of hormonal therapy in transgender people is an area of considerable concern. In addition, concerns about cancer risk in transgender patients have been linked to sexually transmitted infections, increased exposure to well-known risk factors such as smoking and alcohol use, and the lack of adequate access to screening. Several publications have identified cancer as an important priority in transgender health research and called for large-scale studies. The goals of this article are to summarize the evidence on factors that may differentially affect cancer risk in transgender people, assess the relevant cancer surveillance and epidemiologic data available to date, and offer an overview of possible methodological considerations for future studies investigating cancer incidence and mortality in this population.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Ophthalmic Disparities in Transgender Patients

Transgender individuals experience unique challenges with regards to discrimination and access to health care. Further, their unique health-care needs and challenges lead to greater rates of morbidity. This article seeks to review the unique biology of transgender patients and the effects of cross-sex hormone therapy on ophthalmic and non-ophthalmic pathology. Attention is given to topics in neuro-ophthalmology, oculoplastics, and retinal disease.

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.

Understanding and Measuring LGBTQ Pathways to Health: A Scoping Review of Strengths-Based Health Promotion Approaches in LGBTQ Health Research

Health research traditionally has focused on the health risks and deficits of lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, obscuring the determinants that can promote health across the life course. Recognizing, appropriately measuring, and rendering visible these determinants of health is paramount to informing appropriate and engaging health policies, services, and systems for LGBTQ populations. The overarching purpose of this article is to provide an overview of the findings of a scoping review aimed at exploring strengths-based health promotion approaches to understanding and measuring LGBTQ health. Specifically, this scoping review examined peer-reviewed, published academic literature to determine (a) existing methodological frameworks for studying LGBTQ health from a strengths-based health promotion approach, and (b) suggestions for future methodological approaches for studying LGBTQ health from a strengths-based health promotion approach. The findings of this scoping review will be used to inform the development of a study aimed at assessing the health of and improving pathways to health services among LGBTQ populations in Nova Scotia, Canada.

Advancing methods for US transgender health research

PURPOSE OF REVIEW

This article describes methodological challenges, gaps, and opportunities in US transgender health research.

RECENT FINDINGS

Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities.

SUMMARY

Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

A global research synthesis of HIV and STI biobehavioural risks in female-to-male transgender adults

There is a growing interest in HIV infection and sexually transmitted infection (STI) disease burden and risk among transgender people globally; however, the majority of work has been conducted with male-to-female transgender populations. This research synthesis comprehensively reviews HIV and STI research in female-to-male (FTM) transgender adults. A paucity of research exists about HIV and STIs in FTMs. Only 25 peer-reviewed papers (18 quantitative, 7 qualitative) and 11 'grey literature' reports were identified, most in the US or Canada, that include data identifying HIV and STI risks in FTMs (five with fully laboratory-confirmed HIV and/or STIs, and five with partial laboratory confirmation). Little is known about the sexual and drug use risk behaviours contributing to HIV and STIs in FTMs. Future directions are suggested, including the need for routine surveillance and monitoring of HIV and STIs globally by transgender identity, more standardised sexual risk assessment measures, targeted data collection in lower- and middle-income countries, and explicit consideration of the rationale for inclusion/exclusion of FTMs in category-based prevention approaches with MSM and transgender people. Implications for research, policy, programming, and interventions are discussed, including the need to address diverse sexual identities, attractions, and behaviours and engage local FTM communities.

Differences in Sexual Orientation Diversity and Sexual Fluidity in Attractions Among Gender Minority Adults in Massachusetts

This study characterized sexual orientation identities and sexual fluidity in attractions in a community-based sample of self-identified transgender and gender-nonconforming adults in Massachusetts. Participants were recruited in 2013 using bimodel methods (online and in person) to complete a one-time, Web-based quantitative survey that included questions about sexual orientation identity and sexual fluidity. Multivariable logistic regression models estimated adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) to examine the correlates of self-reported changes in attractions ever in lifetime among the whole sample (n = 452) and after transition among those who reported social gender transition (n = 205). The sample endorsed diverse sexual orientation identities: 42.7% queer, 19.0% other nonbinary, 15.7% bisexual, 12.2% straight, and 10.4% gay/lesbian. Overall, 58.2% reported having experienced changes in sexual attractions in their lifetime. In adjusted models, trans masculine individuals were more likely than trans feminine individuals to report sexual fluidity in their lifetime (aRR = 1.69; 95% CI = 1.34, 2.12). Among those who transitioned, 64.6% reported a change in attractions posttransition, and trans masculine individuals were less likely than trans feminine individuals to report sexual fluidity (aRR = 0.44; 95% CI = 0.28, 0.69). Heterogeneity of sexual orientation identities and sexual fluidity in attractions are the norm rather than the exception among gender minority people.

Perceptions of sexual violence among men who have sex with men and individuals on the trans-feminine spectrum in Mongolia

With the growing realisation that sexual violence poses pressing health and human rights concerns for men who have sex with men (MSM) and individuals on the trans-feminine spectrum, research has focused on the context in which sexual violence takes place. Rape myths and other perceptions of sexual violence affect the prevalence of perpetration and the availability of services and support for survivors. Little research has been conducted on rape myths among sexual and gender minority groups, especially in low- and middle-income countries. Two focus groups and 30 in-depth interviews were conducted with MSM and individuals on the trans-feminine spectrum in Ulaanbaatar, Mongolia. A number of rape myths previously noted to be prevalent among Western, heterosexual men, and women were expressed by participants, including the myth that males are never raped, rape as a cause of homosexuality or transgenderism, conceptualisations of prototypical rape as requiring overwhelming force, and victim blaming. However, many of these perceptions appeared to have different origins and effects in these populations. This study illustrates interesting similarities and differences compared to rape myths explored in Western, heterosexual male samples, and draws attention to the need to address community perceptions of sexual violence in sexual health and violence intervention programming.

Cervical Cancer Screening for Patients on the Female-to-Male Spectrum: a Narrative Review and Guide for Clinicians

Guidelines for cervical cancer screening have evolved rapidly over the last several years, with a trend toward longer intervals between screenings and an increasing number of screening options, such as Pap/HPV co-testing and HPV testing as a primary screening. However, gynecological recommendations often do not include clinical considerations specific to patients on the female-to-male (FTM) spectrum. Both patients and providers may not accurately assess risk for HPV and other sexually transmitted infections, understand barriers to care, or be aware of recommendations for cervical cancer screening and other appropriate sexual and reproductive health services for this patient population. We review the evidence and provide guidance on minimizing emotional discomfort before, during, and after a pelvic exam, minimizing physical discomfort during the exam, and making adaptations to account for testosterone-induced anatomical changes common among FTM patients.

The Time Is Now: Attention Increases to Transgender Health in the United States but Scientific Knowledge Gaps Remain

Attention to transgender health has dramatically increased in the U.S. Scientific knowledge gaps in empirical research, however, remain and act as barriers to achieving transgender-related health equity. We conducted a search using PubMed and PsycINFO to identify gaps in empirical, peer-reviewed publications related to adult transgender health in the U.S. between 1981 and 2013. We synthesized these findings and commented on opportunities for improving health research. Reducing health disparities and advancing transgender-related health equity requires greater investment in research that addresses current gaps to more comprehensively respond to the diverse health needs of transgender people.

Syndemics and gender affirmation: HIV sexual risk in female-to-male trans masculine adults reporting sexual contact with cisgender males

Female-to-male trans masculine adults who have sex with cisgender (non-transgender) males (TMSM) represent an understudied population in relation to HIV/sexually transmitted infection (STI) risk. This study examined the role of syndemic conditions and social gender affirmation processes (living full-time in one's identified gender) in potentiating sexual risk among TMSM adults in Massachusetts, US. Cross-sectional data were restricted to TMSM who reported lifetime sexual behaviour with a cisgender male (n = 173; mean age = 29.4, SD = 9.6; 18.5% people of colour; 93.1% non-heterosexual identity; 56.1% hormones/surgery). Sexual risk outcomes were: lifetime STI diagnoses, three or more sexual partners in the previous six months, and condomless anal/vaginal sex at last encounter with a cisgender male. Age- and survey mode-adjusted logistic regression models regressed sexual risk outcomes on the main effect of syndemics (six indicators summed: binge drinking, substance use, depression, anxiety, childhood abuse, intimate partner violence), followed by the interaction of syndemics and social gender affirmation. Syndemics were associated with increased odds of all sexual risk indicators (adjusted odds ratios [aORs] = 1.32-1.55; p < 0.0001). Social gender affirmation moderated the association between syndemics and condomless anal/vaginal sex at last encounter with a cisgender male (p < 0.0001). Syndemics were associated with sexual risk in TMSM who had socially affirmed their gender (aOR = 1.79; 95% CI = 1.42-2.25; p < 0.001), but not among those TMSM who had not (aOR = 0.86; 95% CI = 0.63-1.19; p = 0.37). Findings suggest that syndemic pathways to sexual risk are similar for TMSM who have socially gender affirmed as for cisgender MSM. Integration of syndemics and gender affirmation frameworks is recommended in interventions to address TMSM sexual risk.

Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults

BACKGROUND

Little is known about differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified populations. Using data from a large-scale health survey, we compare the drinking patterns and prevalence of alcohol-related problems of transgender-identified individuals to nontransgender-identified males and females. For transgender-identified people, we examine how various forms of victimization relate to heavy episodic drinking (HED).

METHODS

Cross-sectional surveys were completed by 75,192 students aged 18-29 years attending 120 post-secondary educational institutions in the United States from 2011 to 2013. Self-reported measures included alcohol use, alcohol-related problems, victimization, and sociodemographics, including 3 gender-identity groups: transgender-identified individuals; nontransgender-identified males; and nontransgender-identified females.

RESULTS

Compared to transgender-identified individuals, nontransgender-identified males were more likely to report HED in the past 2 weeks (relative risk=1.42; p=0.006); however, nontransgender-identified males and females reported HED on fewer days than transgender-identified people (incidence-rate ratios [IRRs] ranged from 0.28 to 0.43; p-values<0.001). Compared to transgender-identified people, nontransgender-identified males and females had lower odds of past-year alcohol-related sexual assault and suicidal ideation (odds ratios ranged from 0.24 to 0.45; p-values<0.05). Among transgender-identified people, individuals who were sexually assaulted (IRR=3.21, p=0.011) or verbally threatened (IRR=2.42, p=0.021) in the past year had greater HED days than those who did not experience those forms of victimization.

CONCLUSIONS

Compared to transgender-identified people, nontransgender-identified males and females: have fewer HED occasions (despite nontransgender-identified males having greater prevalence of HED); and are at lower risk for alcohol-related sexual assaults and suicidal ideation. Experiences of sexual assault and verbal threats are associated with greater HED occasions for transgender-identified people.

Legal Protections in Public Accommodations Settings: A Critical Public Health Issue for Transgender and Gender-Nonconforming People

POLICY POINTS

Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender people's health and their ability to access health care.

CONTEXT

Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings.

METHODS

In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings.

FINDINGS

Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed).

CONCLUSIONS

Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities.

Substance Use to Cope with Stigma in Healthcare Among U.S. Female-to-Male Trans Masculine Adults

PURPOSE

Enacted and anticipated stigma exist within healthcare settings for transgender people, but research has yet to examine the effects of these forms of stigma on the substance use behaviors of female-to-male (FTM) trans masculine people.

METHODS

Data were analyzed from the cross-sectional U.S. National Transgender Discrimination Survey, a convenience sample of transgender adults purposively sampled in 2008. Trans masculine respondents (n=2,578) were identified using a two-step method: Step 1, Assigned birth sex; Step 2, Current gender identity. A gender minority stress model of substance use was tested to examine the relation of enacted and anticipated stigma with substance use to cope with mistreatment.

RESULTS

Overall, 14.1% of the sample reported having been refused care by a provider (enacted stigma), 32.8% reported delaying needed medical care when sick/injured, and 39.1% delayed routine preventive care (anticipated stigma). Having been refused care was significantly associated with avoidance of healthcare, including delaying needed medical care when sick/injured and delaying routine preventive medical care. Substance use to cope with mistreatment was self-reported by 27.6% of the sample. Enacted stigma by providers was associated with self-reported substance use to cope. Delays in both needed and preventive care (anticipated stigma) were highly associated with substance use, and attenuated the effect of enacted stigma.

CONCLUSION

Gender minority-related stressors, particularly enacted and anticipated stigma in healthcare, should be integrated into substance use and abuse prevention and intervention efforts with this underserved population.

Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health

This report describes the evolution of a Boston community health center's multidisciplinary model of transgender healthcare, research, education, and dissemination of best practices. This process began with the development of a community-based approach to care that has been refined over almost 20 years where transgender patients have received tailored services through the Transgender Health Program. The program began as a response to unmet clinical needs and has grown through recognition that our local culturally responsive approach that links clinical care with biobehavioral and health services research, education, training, and advocacy promotes social justice and health equity for transgender people. Fenway Health's holistic public health efforts recognize the key role of gender affirmation in the care and well-being of transgender people worldwide.

Pap test use is lower among female-to-male patients than non-transgender women

BACKGROUND

A paucity of empirical research to date has examined cervical cancer screening in female-to-male (FTM) transgender men who retain their natal reproductive structures compared to non-transgender women.

PURPOSE

To examine patient and provider characteristics associated with being up-to-date on Pap tests, with a focus on gender identity and sexual orientation.

METHODS

Retrospective chart review of 5,232 patients (4,882 women, 350 FTM transgender men) at an urban community health center. All HIV-negative primary care patients aged 21-64 years (inclusive) with at least one medical visit during the 2012 calendar year and who had a cervix as of December 31, 2012, were included. Data were analyzed in 2013 using a multilevel logistic regression model nesting patients within providers.

RESULTS

FTM patients were significantly less likely to be up-to-date on Pap tests (AOR=0.63, 95% CI=0.47, 0.85) compared to non-transgender women, after adjusting for individual- and provider-level factors. Behaviorally bisexual patients, compared to patients who had sex with men exclusively, were more likely to be up-to-date (AOR=1.73, 95% CI=1.32, 2.26); patients reporting only sex with women were not significantly more or less likely to be up-to-date (AOR=1.01, 95% CI=0.83, 1.23).

CONCLUSIONS

Transgender patients are not accessing the same level of preventive cervical screening care as non-transgender female patients. There is a need to better understand barriers to care in this population. Contrary to findings in other settings, history of sex with women was not negatively associated with Pap utilization.