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Goldenberg T, Tanner AE, McGuire T, Alonzo J, Mann-Jackson L, Refugio Aviles L, Galindo CA, Bessler PA, Courtenay-Quirk C, Garcia M, Reboussin BA, Rhodes SD. The Role of Stigma and Resilience in Healthcare Engagement Among Transgender Latinas in the U.S. South: Baseline Findings from the ChiCAS Study. J Immigr Minor Health 2024:10.1007/s10903-024-01605-6. [PMID: 38809298 DOI: 10.1007/s10903-024-01605-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 05/30/2024]
Abstract
Research demonstrates that stigma and resilience influence transgender peoples' healthcare use. Less is known about transgender Latinas in the U.S. South who face multilevel barriers to healthcare access. We used baseline data from the ChiCAS intervention study. Using logistic regression, we examined how stigma (perceived discrimination related to gender identity, race/ethnicity, sexual behavior and perceived documentation status and internalized transphobia), and resilience (ethnic group pride and social support) are associated with two healthcare outcomes (use of routine medical care and medically supervised gender-affirming hormones). We also explored barriers to accessing both types of care. After removing 13 participants with missing data, our sample size was 131 transgender Latinas in the U.S. South. Most participants (74.8%, n = 98) received routine medical care in the past year and 57.3% (n = 75) had ever received medically supervised gender-affirming hormones. Reports of discrimination were highest for gender identity and documentation status. Race/ethnicity-based discrimination was positively associated with accessing routine medical care in the past year (OR = 1.94, p = 0.048). Having more social support was positively associated with care (routine care: OR = 3.48, p = 0.002 and gender-affirming hormones: OR = 2.33, p = 0.003). The most commonly reported barriers to accessing both types of care included cost, insurance, and not knowing where to go. Findings highlight the importance of social support for healthcare use among transgender Latinas. Social support may be especially important when considering the unique experiences of discrimination faced by transgender Latinas in the U.S. South.
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Affiliation(s)
- Tamar Goldenberg
- Department of Public Health Education, University of North Carolina Greensboro, 1408 Walker Avenue 437 Mary Channing Coleman Building Greensboro, Winston-Salem, NC, 27402, USA.
| | - Amanda E Tanner
- Department of Public Health Education, University of North Carolina Greensboro, 1408 Walker Avenue 437 Mary Channing Coleman Building Greensboro, Winston-Salem, NC, 27402, USA
| | - Tucker McGuire
- Department of Public Health Education, University of North Carolina Greensboro, 1408 Walker Avenue 437 Mary Channing Coleman Building Greensboro, Winston-Salem, NC, 27402, USA
| | - Jorge Alonzo
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Lilli Mann-Jackson
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Lucero Refugio Aviles
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Carla A Galindo
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Patricia A Bessler
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cari Courtenay-Quirk
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Manuel Garcia
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Beth A Reboussin
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Scott D Rhodes
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, USA
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Kim SJ, Medina M, Park JH, Cho NE, Chang J. Is gender dysphoria associated with increased hospital cost per stay among patients hospitalized for depression? Focus on the racial and regional variance in US hospitals. Front Public Health 2024; 12:1359127. [PMID: 38846620 PMCID: PMC11153705 DOI: 10.3389/fpubh.2024.1359127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/09/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Individuals with gender dysphoria do not identify with their sex assigned at birth and face societal and cultural challenges, leading to increased risk for depression, anxiety, and suicide. Gender dysphoria is a DSM-5 diagnosis but is not necessary for transition therapy. Additionally, individuals with gender dysphoria or who identify as gender diverse/nonconforming may experience "minority stress" from increased discrimination, leading to a greater risk for mental health problems. This study aimed to identify possible health disparities in patients hospitalized for depression with gender dysphoria across the United States. Depression was selected because patients with gender dysphoria are at an increased risk for it. Various patient and hospital-related factors are explored for their association with changes in healthcare utilization for patients hospitalized with depression. Methods The National Inpatient Sample was used to identify nationwide patients with depression (n = 378,552, weighted n = 1,892,760) from 2016 to 2019. We then examined the characteristics of the study sample and investigated how individuals' gender dysphoria was associated with healthcare utilization measured by hospital cost per stay. Multivariate survey regression models were used to identify predictors. Results Among the 1,892,760 total depression inpatient samples, 14,145 (0.7%) patients had gender dysphoria (per ICD-10 codes). Over the study periods, depression inpatients with gender dysphoria increased, but total depression inpatient rates remained stable. Survey regression results suggested that gender dysphoria, minority ethnicity or race, female sex assigned at birth, older ages, and specific hospital regions were associated with higher hospital cost per stay than their reference groups. Sub-group analysis showed that the trend was similar in most racial and regional groups. Conclusion Differences in hospital cost per stay for depression inpatients with gender dysphoria exemplify how this community has been disproportionally affected by racial and regional biases, insurance denials, and economic disadvantages. Financial concerns can stop individuals from accessing gender-affirming care and risk more significant mental health problems. Increased complexity and comorbidity are associated with hospital cost per stay and add to the cycle.
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Affiliation(s)
- Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
| | - Mar Medina
- School of Pharmacy, University of Texas at El Paso, El Paso, TX, United States
| | - Jeong-Hui Park
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, TX, United States
| | - Na-Eun Cho
- College of Business, HongIk University, Seoul, Republic of Korea
| | - Jongwha Chang
- Department of Pharmaceutical Sciences, Irma Lerma Rangel School of Pharmacy, Texas A&M University, College Station, TX, United States
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Atkins K, Bruce J, Kay ES, Musgrove K, Kellar P, MacCarthy S. Transactional sex among adults accessing sexual health services in Alabama, 2008-2022: Prevalence, associated risk factors, and associations with HIV, HCV, and STI diagnosis. Ann Epidemiol 2024; 92:35-39. [PMID: 38360156 DOI: 10.1016/j.annepidem.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The U.S. Deep South bears a disproportionate burden of HIV and other STIs. Transactional sex may influence these epidemics, but few studies have estimated its prevalence or correlates in the Deep South. METHODS We estimated the history of transactional sex among adults accessing an Alabama AIDS Service Organization from 2008-2022, using chi-square tests to examine its sociodemographic and behavioral correlates. We used modified Poisson regression with cluster-robust standard errors to estimate adjusted prevalence ratios (aPR) and 95 % confidence intervals (CI) for the associations between transactional sex and new HIV, hepatitis C (HCV), and STI diagnoses. RESULTS Transactional sex was reported at 944/20,013 visits (4.7 %) and associated with older age, being a cisgender woman or gender minority, identifying as white, diverse drug use, and sharing of drug equipment. Compared to others, clients reporting transactional sex had increased prevalence of syphilis (apR 3.60, 95 % CI 1.16-11.19) and HCV (aPR 1.53, 95 % CI 1.24-1.88). CONCLUSION Using 14 years of community-based data, this study is the first to estimate the relationship between transactional sex and HIV, HCV, and STIs in Alabama and highlights the need address STI burden and diverse drug use among people who transact sex in the Deep South.
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Affiliation(s)
- Kaitlyn Atkins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Josh Bruce
- Birmingham AIDS Outreach, Birmingham, AL, USA
| | - Emma Sophia Kay
- Birmingham AIDS Outreach, Birmingham, AL, USA; Department of Acute, Chronic, and Continuing Care University of Alabama at Birmingham School of Nursing Birmingham, AL, USA
| | | | | | - Sarah MacCarthy
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, USA
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Fein LA, Brenner S, Nogueira NF, Salazar AS, Rodriguez AE, Jones DL, Alcaide ML. Low Levels of HIV Stigma Among Transgender Women Receiving HIV Care. Transgend Health 2024; 9:180-184. [PMID: 38585240 PMCID: PMC10998008 DOI: 10.1089/trgh.2021.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite the prevalence of HIV among transgender women (TGW), gaps exist in understanding the impact of HIV-related stigma (HRS) on TGW with HIV. This is a small cross-sectional pilot study examining HRS in TGW (n=18) with HIV in Miami, FL, who completed a survey during an HIV clinical visit. In contrast with previous studies, results demonstrated low levels of HRS and suggest the potential of increasing acceptance of TGW with HIV as a contributing factor. Larger studies are needed to explore factors underlying HRS with the aim of further reducing stigma among TGW with HIV.
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Affiliation(s)
- Lydia A. Fein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sara Brenner
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholas F. Nogueira
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ana S. Salazar
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan E. Rodriguez
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Deborah L. Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Watson DL, Listerud L, Drab RA, Lin WY, Momplaisir FM, Bauermeister JA. HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis. J Int AIDS Soc 2024; 27:e26211. [PMID: 38332521 PMCID: PMC10853582 DOI: 10.1002/jia2.26211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024] Open
Abstract
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.
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Affiliation(s)
- Dovie L. Watson
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Louis Listerud
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ryan A. Drab
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Willey Y. Lin
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Florence Marie Momplaisir
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - José A. Bauermeister
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Saadat M, Keramat A, Jahanfar S, Nazari AM, Ranjbar H, Motaghi Z. Barriers and Facilitators to Accessing Sexual and Reproductive Health Services Among Transgender People: A Meta-Synthesis. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2024; 54:40-51. [PMID: 37470127 DOI: 10.1177/27551938231187863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
The availability and accessibility of sexual and reproductive health (SRH) services for transgender individuals are crucial. This population is deprived of health care due to rejection, stigma, gender-based discrimination, confidentiality, and violence. This review attempts to provide readers with an account of the fundamental problems that the transgender population faces regarding experiences of SRH. This meta-synthesis review applied the Social-Ecological Model (SEM) to address trans individuals' SRH factors. The databases were searched using "SRH" and "transgender" keywords. Fifty studies were finally selected. All studies were qualitative, including 36 semi-structured/ in-depth interviews, two focus group studies, and 12 interviews and focus group studies. The Social-Ecological Model application illustrates the impact of individual, interpersonal, institutional, and social factors on the condition of SRH among transgender individuals. This meta-synthesis reinforces multiple levels of factors that influence the SRH of transgender individuals. These include limited information, lack of awareness, low socioeconomic status, stigma and discrimination, and social deprivation. Interventions are urgently needed to provide better sexual and reproductive well-being for transgender individuals.
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Affiliation(s)
- Mina Saadat
- Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Afsaneh Keramat
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Shayesteh Jahanfar
- Tufts School of Medicine, Department of Public Health and Community Medicine, Boston, MA, USA
| | - Ali Mohammad Nazari
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Hadi Ranjbar
- Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Motaghi
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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Storholm ED, Ogunbajo A, Nacht CL, Opalo C, Horvath KJ, Lyman P, Flynn R, Reback CJ, Blumenthal J, Moore DJ, Bolan R, Morris S. Facilitators of PrEP Persistence among Black and Latinx Transgender Women in a PrEP Demonstration Project in Southern California. Behav Med 2024; 50:63-74. [PMID: 35993278 PMCID: PMC9943802 DOI: 10.1080/08964289.2022.2105794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022]
Abstract
Black and Latinx transgender women in the United States (U.S.) are at disproportionately high risk for HIV. Although HIV pre-exposure prophylaxis (PrEP) reduces the risk of HIV infection, uptake and persistence (i.e., ability to continue taking PrEP over time) can be a challenge for Black and Latinx transgender women due to myriad social and structural forces. In this qualitative study, we present unique data on the facilitators of PrEP persistence from Black and Latinx transgender women who initiated PrEP and exhibited varying levels of persistence during a demonstration project in Southern California. PrEP persistence was assessed by collecting quantitative intracellular tenofovir-diphosphate (TFV-DP) levels on dried blood spot (DBS) samples collected at weeks 12 and 48. Informed by the socioecological framework, we conducted and analyzed interviews using qualitative content analysis to determine themes on the facilitators of PrEP persistence. Individual-level facilitators included the use of reminders, having high individual-level HIV risk perception, feeling empowered to take PrEP, and reporting having improved peace of mind and mental health because of taking PrEP. Interpersonal/Community-level facilitators included feeling motivation to prevent HIV in the community, motivation to prevent HIV in the context of sex work, and having high community-level risk perception. Structural-level facilitators included having positive experiences in affirming healthcare settings and having PrEP visits combined with other gender-related healthcare visits. Interventions aiming to increase PrEP uptake and persistence among Black and Latinx transgender women in the U.S. should harness the multiple levels of support exhibited by those who were able to start and persist on PrEP in the face of the myriad social and structural barriers.
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Affiliation(s)
- Erik D. Storholm
- School of Public Health, San Diego State University
- RAND Corporation
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles
| | - Adedotun Ogunbajo
- RAND Corporation
- Department of Behavioral and Social Sciences, Brown University School of Public Health
| | | | | | | | | | | | - Cathy J. Reback
- Center for HIV Identification, Prevention and Treatment Services, Department of Family Medicine, University of California Los Angeles
- Friends Research Institute
| | - Jill Blumenthal
- AntiViral Research Center, University of California, San Diego School of Medicine
| | - David J. Moore
- AntiViral Research Center, University of California, San Diego School of Medicine
| | | | - Sheldon Morris
- AntiViral Research Center, University of California, San Diego School of Medicine
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Mehta SD, Otieno FO, Kimani J, Wahome E, Okal D, Roy A, van der Elst E, Graham SM, Sanders EJ, Bailey RC. Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men. BMC Public Health 2023; 23:1493. [PMID: 37542212 PMCID: PMC10403860 DOI: 10.1186/s12889-023-16348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/18/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Worldwide, sexual and gender minority individuals have disproportionate burden of HIV. There are limited quantitative data from sub-Saharan Africa on the intersection of risks experienced by transgender women (TGW) in comparison to cis-men who have sex with men (MSM). This analysis addresses this gap by comparing reported stigma, psychosocial measures of health, and sexual risk practices between TGW and cis-MSM in Kenya. METHODS We analyzed data from the baseline visit of an ongoing prospective cohort study taking place in three diverse metropolitan areas. Eligible participants were HIV-negative, assigned male at birth, ages 18-29 years, and reported anal intercourse in the past 3 months with a man or TGW. Data collected by audio computer assisted self-interview included sociodemographic measures, and sexual practices occurring in the past 3 months. Multivariable regressions assessed differences between TGW and cis-MSM in selected sexual practices, depressive symptoms, alcohol and drug use, and stigma. RESULTS From September, 2019, through May, 2021, 838 participants were enrolled: 108 (12.9%) TGW and 730 (87.1%) cis-MSM. Adjusting for sociodemographic variables, TGW were more likely than cis-MSM to report: receptive anal intercourse (RAI; adjusted prevalence ratio [aPR] = 1.59, 95% CI: 1.32 - 1.92), engaging in group sex (aPR = 1.15, 95% CI: 1.04 - 1.27), 4 or more male sex partners (aPR = 3.31, 95% CI: 2.52 - 4.35), and 3 or more paying male sex partners (aPR = 1.58, 95% CI: 1.04 - 2.39). TGW were also more likely to report moderate to severe depressive symptoms (aPR = 1.42, 95% CI: 1.01 - 1.55), and had similar alcohol and drug abuse scores as cis-MSM. In sensitivity analysis, similar to TGW, male-identifying individuals taking feminizing gender affirming therapy had an increased likelihood of reporting RAI and group sex, and greater numbers of male sex partners and paying male sex partners relative to cis-MSM. CONCLUSIONS Across three metropolitan areas in Kenya, TGW were more likely to report depressive symptoms and increased sexual risk taking. We identified a need for research that better characterizes the range of gender identities. Our analysis affirms the need for programmatic gender-affirming interventions specific to transgender populations in Kenya and elsewhere in Africa.
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Affiliation(s)
- Supriya D Mehta
- Division of Epidemiology & Biostatistics, University of Illinois Chicago School of Public Health, 1750 W. Harrison Street, Jelke 1121, Chicago, IL, 60612, USA.
- Division of Infectious Disease Medicine, Rush University College of Medicine, Chicago, USA.
| | | | - Joshua Kimani
- Partners for Health and Development in Africa, Nairobi, Kenya
- University of Manitoba, Winnipeg, Canada
| | - Elizabeth Wahome
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Duncan Okal
- Nyanza Reproductive Health Society, Kisumu, Kenya
| | - Abhishikta Roy
- Division of Epidemiology & Biostatistics, University of Illinois Chicago School of Public Health, 1750 W. Harrison Street, Jelke 1121, Chicago, IL, 60612, USA
| | - Elise van der Elst
- Global Health Department, University of Amsterdam, Amsterdam, The Netherlands
| | - Susan M Graham
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Eduard J Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Global Health Department, University of Amsterdam, Amsterdam, The Netherlands
- University of Oxford, Oxford, UK
- Aurum Institute, Johannesburg, South Africa
| | - Robert C Bailey
- Division of Epidemiology & Biostatistics, University of Illinois Chicago School of Public Health, 1750 W. Harrison Street, Jelke 1121, Chicago, IL, 60612, USA
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King WM, Jadwin-Cakmak L, Trammell R, Gamarel KE. Structural vulnerability as a conceptual framework for transgender health research: findings from a community needs assessment of transgender women of colour in Detroit. CULTURE, HEALTH & SEXUALITY 2023; 25:681-697. [PMID: 35736653 PMCID: PMC9780405 DOI: 10.1080/13691058.2022.2086709] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/02/2022] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Wesley M King
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Racquelle Trammell
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
- Trans Sistas of Colour Project, Detroit, MI, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
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Muyanga N, Isunju JB, Ssekamatte T, Nalugya A, Oputan P, Kiguli J, Kibira SPS, Wafula ST, Ssekamatte D, Mugambe RK, Wanyenze RK, Orza L. Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda. BMC Womens Health 2023; 23:250. [PMID: 37161437 PMCID: PMC10170825 DOI: 10.1186/s12905-023-02402-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/28/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda. METHODS This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding. RESULTS At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities. CONCLUSION The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.
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Affiliation(s)
- Naume Muyanga
- Programs Department, Transgender Equality Uganda, Kampala, Uganda
| | - John Bosco Isunju
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Tonny Ssekamatte
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda.
| | - Aisha Nalugya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Patience Oputan
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Juliet Kiguli
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Simon Peter S Kibira
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Solomon Tsebeni Wafula
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - David Ssekamatte
- Department of Management, Uganda Management Institute, K.A.R. Road, Kampala, Uganda
| | - Richard K Mugambe
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, New Mulago Hill Road, Mulago Kampala, Uganda
| | - Luisa Orza
- Frontline AIDS, 35 New England Street, Brighton, United Kingdom
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11
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Gamarel KE, Jadwin-Cakmak L, King WM, Hughes L, Abad J, Trammell R, Maguire A, Shackelford V, Connolly M, Rescoe T, Williams A, Harper GW. Improving Access to Legal Gender Affirmation for Transgender Women Involved in the Criminal-Legal System. JOURNAL OF CORRECTIONAL HEALTH CARE 2023; 29:12-15. [PMID: 36037008 PMCID: PMC10081699 DOI: 10.1089/jchc.21.09.0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Transgender women of color experience interlocking systems of oppression rooted in racism and transphobia, which fuel economic vulnerability and overrepresentation in the criminal-legal system. Legal gender affirmation, which refers to changing one's name and gender marker on official documents, has the potential to mitigate these issues by improving access to employment, housing, education, health care, and social services. These services are particularly important for transgender women of color with criminal records, a history of incarceration, or other legal infractions; however, 23 states have policies that restrict access to legal gender affirmation for these individuals. Alongside eliminating restrictive policies to obtain legal gender affirmation, medical-legal partnerships in these states may address recidivism and health inequities among transgender women of color.
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Affiliation(s)
- Kristi E. Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Wesley M. King
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Landon Hughes
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Julisa Abad
- Trans Sistas of Color Project, Detroit, Michigan, USA
- Fair Michigan Foundation, Detroit, Michigan, USA
| | - Racquelle Trammell
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Trans Sistas of Color Project, Detroit, Michigan, USA
| | | | | | - Maureen Connolly
- Department of Pediatrics, Henry Ford Health System, Detroit, Michigan, USA
| | | | | | - Gary W. Harper
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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12
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Logie CH, Kinitz DJ, Gittings L, Persad Y, Lacombe-Duncan A, Poteat T. Eliciting critical hope in community-based HIV research with transgender women in Toronto, Canada: methodological insights. Health Promot Int 2022; 37:ii37-ii47. [PMID: 35213717 PMCID: PMC9226654 DOI: 10.1093/heapro/daac017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Critical hope centres optimism and possibilities for change in the midst of struggles for social justice. It was a central tenet of early participatory pedagogy and HIV research. However, critical hope has been overlooked in contemporary HIV research that largely focuses on risk and biomedical interventions in ways that obscure collective agency and community strengths. We conducted a community-based study with transgender (trans) women of colour in Toronto, Canada to adapt an evidence-based HIV prevention intervention. Participants resisted a focus on HIV, instead calling researchers to centre journeys to self-love in contexts of social exclusion. In response, we piloted three arts-based, participatory methods generated with community collaborators: (i) affirmation cards sharing supportive messages with other trans women, (ii) hand-held mirrors for reflecting and sharing messages of self-acceptance and (iii) anatomical heart images to visualize coping strategies. Participants generated solidarity and community through shared stories of self-acceptance within contexts of pain, exclusion and loss. Narratives revealed locating agency and self-acceptance through community connectedness. Critical hope was a by-product of this participatory process, whereby participants shared personal and collective optimism. Participatory and arts-based methods that centre self-acceptance and solidarity can nurture resistance to pathologizing discourses in HIV research. Centring critical hope and participant-generated methodologies is a promising approach to transformative health promotion and intervention research. These methodological insights can be engaged in future participatory work with other marginalized groups facing dominant biomedical risk discourses. Critical hope holds potential as a participatory health promotion strategy for envisioning possibilities for sustainable change.
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Affiliation(s)
| | - David J Kinitz
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Lesley Gittings
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON M5S 1V4, Canada
| | - Yasmeen Persad
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5G 1N8, Canada
- 519 Community Centre, Toronto, ON M4Y 2C9, Canada
| | - Ashley Lacombe-Duncan
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5G 1N8, Canada
- Faculty of Social Work, University of Michigan, Ann Arbor, MI 48109, USA
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC 27599-7240, USA
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13
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Sherman ADF, Balthazar M, Klepper M, Febres-Cordero S, Valmeekanathan A, Prakash D, Cimino AN, Wharton W, Allure K, Kelly U. Approach and avoidant coping among black transgender women who have experienced violence: A qualitative analysis. Psychol Serv 2022; 19:45-61. [PMID: 34460276 PMCID: PMC9891319 DOI: 10.1037/ser0000581] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Black transgender women face nearly universal exposure to violence. Coping behaviors among cisgender women who have survived violence are well delineated; however, there are relatively few studies examining coping strategies for transgender women. The purpose of this qualitative study was to identify and characterize coping behaviors employed by Black transgender women (from Baltimore, MD and Washington, DC metropolitan areas) following an experience of violence. Secondary qualitative data analysis was conducted using framework analysis to explore narratives of 19 Black transgender women. Themes regarding avoidant and approach coping behaviors were developed within the context of existing literature. Approach coping behavior themes included: Help-Seeking, Seeking Guidance and Support, Self-Protecting Behavior, Positive Reappraisal, Self-Affirmation, Self-Care, Connection to a Higher Power, and Acceptance. Avoidant coping behavior themes included: Cognitive Avoidance, Substance, Alcohol, and Tobacco Use, Emotional Discharge, and Seeking Alternative Rewards. Participants employed similar coping behaviors as seen among cisgender women survivors of violence. However, several unique applications of approach coping mechanisms were identified including self-protecting behavior and self-affirming behavior. Culturally informed application of the identified coping behaviors can be taught and integrated into trauma-informed mental health interventions to promote strength and resilience among Black transgender women. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | - Monique Balthazar
- The Nell Hodgson Woodruff School of Nursing, Emory University,Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University
| | - Meredith Klepper
- The Johns Hopkins University School of Nursing, Johns Hopkins University
| | | | | | - Diane Prakash
- The Nell Hodgson Woodruff School of Nursing, Emory University
| | - Andrea N. Cimino
- Danger Assessment Training and Technical Assistance Center, Johns Hopkins School of Nursing
| | - Whitney Wharton
- The Nell Hodgson Woodruff School of Nursing, Emory University
| | - Kisha Allure
- Casa Ruby, Washington, District of Columbia, United States
| | - Ursula Kelly
- The Nell Hodgson Woodruff School of Nursing, Emory University,Atlanta VA Health Care System, Atlanta, Georgia, United States
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14
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Mora M, Rincon G, Bourrelly M, Maradan G, Freire Maresca A, Michard F, Rouveix E, Pannetier J, Leriche D, Alain T, Yazdanpanah Y, Michels D, Spire B. Living conditions, HIV and gender affirmation care pathways of transgender people living with HIV in France: a nationwide, comprehensive, cross-sectional, community-based research protocol (ANRS Trans&HIV). BMJ Open 2021; 11:e052691. [PMID: 34916316 PMCID: PMC8679115 DOI: 10.1136/bmjopen-2021-052691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Transgender identity is poorly accepted in France, and data on living conditions and the daily difficulties transgender people encounter are scarce. This lack of data reinforces their invisibility in social life, contributes to their stigmatisation and probably increases the burden of HIV infection, especially for HIV-positive transgender people (TRHIV). The main objective of the community-based research study ANRS Trans&HIV is to identify personal and social situations of vulnerability in TRHIV, the obstacles they encounter in terms of access to and retention in medical care, and their gender affirmation and HIV care needs. METHODS AND ANALYSIS ANRS Trans&HIV is a national, comprehensive, cross-sectional survey of all TRHIV currently being followed in HIV care units in France. TRHIV women are exclusively included in the quantitative component, and TRHIV men in the qualitative component. Data are collected by community-based interviewers and will be analysed to explore patient care pathways and living conditions in the TRHIV population with regard to gender affirmation and HIV. Data collection began in October 2020 and should be completed in December 2021. The statistical analyses techniques used will be adapted to each of the study's objectives and to the type of data collected (cross-sectional (questionnaires) and retrospective (biographical trajectory)). The study's results will provide a greater understanding of TRHIV health needs in order to suggest possible national recommendations for comprehensive HIV and gender affirmation medical care. ETHICS AND DISSEMINATION ANRS Trans&HIV was approved by Inserm's Ethical Evaluation Committee (no 20-694 on 12 May 2020) and is registered with the National Commission on Informatics and Liberty under number 2518030720. Potential participants are informed about the study through an information note provided by their attending HIV physician. All results published in peer-reviewed journals will be disseminated to the HIV transgender community, institutional stakeholders and healthcare providers. TRIAL REGISTRATION NUMBER NCT04849767.
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Affiliation(s)
- Marion Mora
- Aix Marseille Univ, Inserm, IRD, ISSPAM, SESSTIM UMR 1252, Marseille, Provence-Alpes-Côte d'Azur, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, Provence-Alpes-Côte d'Azur, France
| | | | - Michel Bourrelly
- Aix Marseille Univ, Inserm, IRD, ISSPAM, SESSTIM UMR 1252, Marseille, Provence-Alpes-Côte d'Azur, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Gwenaëlle Maradan
- Aix Marseille Univ, Inserm, IRD, ISSPAM, SESSTIM UMR 1252, Marseille, Provence-Alpes-Côte d'Azur, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, Provence-Alpes-Côte d'Azur, France
| | - Anaenza Freire Maresca
- Service de médecine interne, UFR Paris Île-de-France Ouest, Hopital Ambroise-Pare, Boulogne-Billancourt, Île-de-France, France
| | - Florence Michard
- Inserm, IAME, UMR 1137, université Paris Diderot, Hopital Bichat - Claude-Bernard, Paris, Île-de-France, France
| | - Elisabeth Rouveix
- Service de médecine interne, UFR Paris Île-de-France Ouest, Hopital Ambroise-Pare, Boulogne-Billancourt, Île-de-France, France
| | - Julie Pannetier
- Paris Descartes University, IRD, ERL Inserm SAGESUD, CEPED, Paris, Île-de-France, France
| | - Diane Leriche
- Collectif Interassociatif coordination, Groupe Interassociatif Traitement & Recherche Thérapeutique (TrT5), Paris, France
| | - Tristan Alain
- AIDES, Pantin, Île-de-France, France
- Community-Based Research Laboratory, Coalition Internationale Sida PLUS, Pantin, France
| | - Yazdan Yazdanpanah
- Inserm, IAME, UMR 1137, université Paris Diderot, Hopital Bichat - Claude-Bernard, Paris, Île-de-France, France
| | - David Michels
- AIDES, Pantin, Île-de-France, France
- Community-Based Research Laboratory, Coalition Internationale Sida PLUS, Pantin, France
| | - Bruno Spire
- Aix Marseille Univ, Inserm, IRD, ISSPAM, SESSTIM UMR 1252, Marseille, Provence-Alpes-Côte d'Azur, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, Provence-Alpes-Côte d'Azur, France
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15
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Gamarel K, King WM, Mouzoon R, Xie H, Stanislaus V, Iwamoto M, Baxter K, Suico S, Nemoto T, Operario D. A "tax" on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area. CULTURE, HEALTH & SEXUALITY 2021; 23:1763-1778. [PMID: 32924839 PMCID: PMC7956137 DOI: 10.1080/13691058.2020.1809711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/10/2020] [Indexed: 06/02/2023]
Abstract
Many transgender (trans) young adults migrate to urban enclaves with known infrastructures to fulfil gender affirmation needs such as obtaining trans-inclusive healthcare and support. This study sought to explore experiences of intranational migration (i.e. migration within a single country) for gender affirmation among trans young adults who relocated to San Francisco. A convenience sample of 61 trans young adults aged 18 to 29 (32% nonbinary, 28% trans women, and 40% trans men; 84% identified as a person of colour) participated in a one-time qualitative interview as part of a larger study. Thematic analysis was used to develop and refine the codes and themes. Three overarching themes became apparent regarding intranational migration and gender affirmation needs: (1) access to basic gender affirmation needs; (2) safety; and (3) the price of gender affirmation. Migration for gender affirmation and safety placed informants at risk for structural vulnerabilities including homelessness, unemployment and racism. Despite these structural vulnerabilities, participants were willing to "pay" the price in order to gain gender affirmation and safety. Findings underscore the importance of moving beyond individual-level risk factors to understand how unmet gender affirmation needs may place trans young adults in structurally vulnerable positions that can affect health and wellness.
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Affiliation(s)
- Kristi Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Wesley M. King
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Raha Mouzoon
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Hui Xie
- Public Health Institute, Oakland, CA, USA
| | | | | | | | | | | | - Don Operario
- Department of Behavior and Social Sciences, Brown University School of Public Health, Providence, RI, USA
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16
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Chong LSH, Kerklaan J, Clarke S, Kohn M, Baumgart A, Guha C, Tunnicliffe DJ, Hanson CS, Craig JC, Tong A. Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review. JAMA Pediatr 2021; 175:1159-1173. [PMID: 34279538 DOI: 10.1001/jamapediatrics.2021.2061] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Lauren S H Chong
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jasmijn Kerklaan
- Kids Research, The Children's Hospital at Westmead, Westmead, Australia.,Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Simon Clarke
- Centre for Research into Adolescent's Health, Department of Adolescent and Young Adult Medicine, Westmead Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Michael Kohn
- Centre for Research into Adolescent's Health, Department of Adolescent and Young Adult Medicine, Westmead Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Amanda Baumgart
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Chandana Guha
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
| | - David J Tunnicliffe
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, Australia.,Kids Research, The Children's Hospital at Westmead, Westmead, Australia
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17
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Rhodes SD, Kuhns LM, Alexander J, Alonzo J, Bessler PA, Courtenay-Quirk C, Denson DJ, Evans K, Galindo CA, Garofalo R, Gelaude DJ, Hotton AL, Johnson AK, Mann-Jackson L, Muldoon A, Ortiz R, Paul JL, Perloff J, Pleasant K, Reboussin BA, Refugio Aviles L, Song EY, Tanner AE, Trent S. Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021. [PMID: 34370565 DOI: 10.1521/aeap.2021.33.4.345]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.
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Affiliation(s)
- Scott D Rhodes
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lisa M Kuhns
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | | | - Jorge Alonzo
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | - Damian J Denson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kaiji Evans
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Carla A Galindo
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert Garofalo
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | | | - Anna L Hotton
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Amy K Johnson
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | - Lilli Mann-Jackson
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Abigail Muldoon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | - Reyna Ortiz
- Chicago House and Social Service Agency, Chicago, Illinois
| | | | - Judy Perloff
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Kevin Pleasant
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Beth A Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | - Amanda E Tanner
- University of North Carolina Greensboro, Greensboro, North Carolina
| | - Scott Trent
- Triad Health Project, Greensboro, North Carolina
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18
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Rhodes SD, Kuhns LM, Alexander J, Alonzo J, Bessler PA, Courtenay-Quirk C, Denson DJ, Evans K, Galindo CA, Garofalo R, Gelaude DJ, Hotton AL, Johnson AK, Mann-Jackson L, Muldoon A, Ortiz R, Paul JL, Perloff J, Pleasant K, Reboussin BA, Refugio Aviles L, Song EY, Tanner AE, Trent S. Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:345-360. [PMID: 34370565 PMCID: PMC8565450 DOI: 10.1521/aeap.2021.33.4.345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.
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Affiliation(s)
- Scott D Rhodes
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lisa M Kuhns
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | | | - Jorge Alonzo
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | - Damian J Denson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kaiji Evans
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Carla A Galindo
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert Garofalo
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | | | - Anna L Hotton
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Amy K Johnson
- Northwestern University, Department of Pediatrics, Feinberg School of Medicine, and the Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | - Lilli Mann-Jackson
- Department of Social Sciences and Health Policy and CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Abigail Muldoon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Potocsnak Family Division of Adolescent and Young Adult Medicine, Chicago, Illinois
| | - Reyna Ortiz
- Chicago House and Social Service Agency, Chicago, Illinois
| | | | - Judy Perloff
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Kevin Pleasant
- Chicago House and Social Service Agency, Chicago, Illinois
| | - Beth A Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | - Amanda E Tanner
- University of North Carolina Greensboro, Greensboro, North Carolina
| | - Scott Trent
- Triad Health Project, Greensboro, North Carolina
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Poteat T, Mayo-Wilson LJ, Pereira N, Wright BN, Smout SA, Sawyer AN, Cathers L, Zimmerman RS, Grigsby SR, Benotsch EG. U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment. BMC Public Health 2021; 21:1394. [PMID: 34261464 PMCID: PMC8281671 DOI: 10.1186/s12889-021-11471-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background Transgender women in the United States (U.S.) experience a disproportionate burden of HIV infection and challenges to engagement in HIV prevention and care. This excess burden is driven by structural and economic inequities. Microeconomic interventions may be effective strategies for reducing HIV inequities for this population. However, few studies have explored transgender women’s preferences for microeconomic interventions to address structural determinants of HIV vulnerability. Methods We conducted individual interviews with 19 adult transgender women in 2 U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Results The majority (74%) of transgender women were racial/ethnic minorities with mean age of 26.3 years. 89% were currently economically vulnerable; and 23% were employed full-time. 37% reported living with HIV. Participants expressed strong support for unrestricted vouchers, with many expressing the need for funds to support gender-affirming interventions. Assistance with how to budget and save and support for job acquisition, career planning, and employment sustainment were also preferred, including access to non-stigmatizing employment. Visible transgender leadership, group empowerment, and small (rather than large) numbers of participants were considered important aspects of intervention design for transgender women, including outreach through existing transgender networks to facilitate inclusion. Incorporating HIV counseling and testing to reduce vulnerability to HIV was acceptable. However, transgender women enrolled in the study preferred that HIV not be the focus of an intervention. Conclusions Flexible microeconomic interventions that support gender affirming interventions, improve financial literacy, and provide living-wage non-stigmatizing employment are desired by economically vulnerable transgender women. While not focused on HIV, such interventions have the potential to reduce the structural drivers of HIV vulnerability among transgender women.
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Affiliation(s)
- Tonia Poteat
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, CB #7240, Chapel Hill, NC, 27516, USA.
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Sciences, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, 47405, USA.,Global & Public Health Division, Johns Hopkins University School of Nursing, Community, 525 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Nastacia Pereira
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, CB #7240, Chapel Hill, NC, 27516, USA
| | - Brittanni N Wright
- Department of Applied Health Sciences, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, 47405, USA
| | - Shelby A Smout
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Ashlee N Sawyer
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Lauretta Cathers
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Rick S Zimmerman
- Wayne State University, College of Nursing, 5557 Cass Avenue, Detroit, MI, 48202, USA
| | - Sheila R Grigsby
- University of Missouri St. Louis, College of Nursing, 221 NAB South Campus, University Blvd, St. Loius, MO, 63121, USA
| | - Eric G Benotsch
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
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