Factors associated with healthcare avoidance among transgender women in Argentina

Factors associated with prior testing for HIV, Syphilis, and Hepatitis B and C among transgender women and travestis in Brazil

OBJECTIVE

To investigate the prior testing for HIV, syphilis, hepatitis B (HBV), and hepatitis C (HCV) among transgender women and travestis (TGW) in five Brazilian cities and identify factors associated with each of these previous tests.

METHODS

This is a cross-sectional study with the recruitment of TGW through respondent-driven sampling (TransOdara Study). The investigated outcome variable was prior testing for HIV, syphilis, HBV, and HCV in the last 12 months. The association between sociodemographic and behavioral factors with the outcome was analyzed using a binomial logistic regression with mixed effects. Adjusted odds ratios (aOR) and 95% confidence intervals (CI95%) were estimated.

RESULTS

The proportions of individuals with prior testing in the past year were as follows: 56.3% for HIV, 58.0% for syphilis, 42.1% for HBV, and 44.7% for HCV. Negative associations with prior testing were observed for individuals aged 35 years or older, whereas positive associations were found for those with high school education, those who experienced verbal or psychological violence in the last 12 months, and those who had commercial or casual partners in the last 6 months.

CONCLUSION

There was low frequency of testing in the 12 months preceding the study for HIV, syphilis, HBV, and HCV compared to the guidelines established by the Ministry of Health. Expanding access to and engagement with healthcare and prevention services for TGW is an essential strategy in reducing the transmission chain of HIV and other sexually transmitted infections (STIs).

Estimate and needs of the transgender adult population: the SPoT study

BACKGROUND

Despite the increasing interest in transgender health research, to date little is known about the size of the transgender and gender diverse (TGD) population.

METHODS

A web-based questionnaire survey was developed, including a collection of socio-demographic characteristics and disseminated online through social media. Gender incongruence was evaluated by using a 2-item approach assessing gender recorded at birth and gender identity. The primary objective of the present population-based study was to estimate the proportion of TGD people across ages among a large sample of people who answered a web-based survey. The secondary endpoints were to identify gender-affirming needs and possible barriers to healthcare access.

RESULTS

A total of 19,572 individuals participated in the survey, of whom 7.7% reported a gender identity different from the sex recorded at birth. A significantly higher proportion of TGD people was observed in the youngest group of participants compared with older ones. Among TGD people who participated in the study, 58.4% were nonbinary, and 49.1% experienced discrimination in accessing health care services. Nonbinary TGD participants reported both the need for legal name and gender change, along with hormonal and surgical interventions less frequently compared to binary persons.

CONCLUSIONS

Being TGD is not a marginal condition In Italy. A large proportion of TGD persons may not need medical and surgical treatments. TGD people often experience barriers to healthcare access relating to gender identity.

Gender Identity Stigma in Transgender Women Is Higher After Gender-Affirming Vaginoplasty

Gender affirmation may reduce stigma and gender-based discrimination that drive increased behaviors that can lead to HIV in transgender women (TW). For many TW, vaginoplasty is gender affirming, yet has not been previously evaluated with regard to likelihood of HIV. This pilot study of TW aimed to evaluate the influence of gender-affirming vaginoplasty on stigma and the drivers of HIV acquisition. Adult TW without HIV were recruited. Interviewer-administered surveys were used to assess demographics, gender identity stigma, psychosocial factors, importance of and satisfaction with gender affirmation, and behaviors that increase the likelihood of HIV in TW who had either undergone gender-affirming vaginoplasty (TWWV) or who had not (TWWOV). Statistical analysis was conducted using descriptive statistics, Fisher's exact tests, and Wilcoxon rank-sum tests. Thirty TW without HIV (19-83 years old) participated (TWWV = 10; TWWOV = 20). The majority identified with ethnic minority groups (n = 21, 70%) and on gender-affirming hormone therapy (n = 25, 83%). Gender identity stigma (38.0; 32.15, p = .03) and social oppression (53.6; 39.4, p = .05) scores were significantly higher among TWWV compared with TWWOV. Satisfaction with body (3.10; 1.95, p = .01), appearance (3.10; 2.10, p = .02), and femininity (3.40; 2.25, p = .001) were higher among TWWV than TWWOV. Present (n = 8, 27%) and past (n = 16, 53%) survival sex work, multiple sex partners (n = 16, 53%), and receptive condomless anal intercourse (n = 10, 33%) were reported but did not vary significantly between groups. Behaviors that may lead to HIV acquisition and their underlying drivers, including gender identity stigma, are present after gender-affirming vaginoplasty. As this procedure continues to increase among TW, interventions to mitigate chances of HIV acquisition are critically needed in this population.

Correlation between gender-based violence and poor treatment outcomes among transgender women living with HIV in Brazil

BACKGROUND

Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil.

METHODS

A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics.

RESULTS

A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79).

CONCLUSION

Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03525340.

Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach

BACKGROUND

Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people.

METHODS

This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms.

RESULTS

Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities.

CONCLUSIONS

The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Does discrimination prevent transgender and gender diverse people from seeking healthcare?: A nationwide cohort study in South Korea

Introduction

Using Asia's first nationwide cohort dataset, this study aimed to assess the prevalence of anti-transgender discrimination and healthcare avoidance and delay (HAD) and examine their associations among transgender and gender diverse (TGD) adults in South Korea.

Methods

We analyzed a two-wave (2020-2021) longitudinal dataset of 190 Korean TGD adults. Anti-transgender discrimination were classified accordingly: experienced at (1) neither wave, (2) baseline (2020) only, (3) follow-up (2021) only, and (4) both waves. We also asked about HAD in the past 12 months at follow-up for both transition-related and non-transition-related healthcare services. Multivariate modified Poisson regression was used to examine the associations between anti-transgender discrimination and HAD.

Results

Of 190 participants, 102 (53.7%) experienced anti-transgender discrimination at both waves, and 130 (68.4%) reported HAD at follow-up. Compared to those without any experiences of anti-transgender discrimination, those who experienced it in both waves had a 1.78-times (95% CI: 1.21-2.63) higher prevalence of non-transition-related HAD, but not among those who experienced it in either wave. In contrast, anti-transgender discrimination was not associated with transition-related HAD.

Conclusion

In order to enhance healthcare access for transgender and gender diverse (TGD) individuals, it is necessary to implement interventions, such as anti-discrimination laws, that protect them from discrimination.

Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh

INTRODUCTION

In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs.

METHODS

This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks.

RESULTS

This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges.

CONCLUSION

The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.

Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study

BACKGROUND

Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently.

METHODS

We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently.

RESULTS

Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings.

CONCLUSIONS

Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings.

Oral and anal microbiome from HIV-exposed individuals: role of host-associated factors in taxa composition and metabolic pathways

Evidence indicates that the microbiome plays a significant role in HIV immunopathogenesis and associated complications. This study aimed to characterize the oral and anal microbiome of Men who have Sex with Men (MSM) and Transgender Women (TGW), with and without HIV. One hundred and thirty oral and anal DNA-derived samples were obtained from 78 participants and subjected to shotgun metagenomics sequencing for further microbiome analysis. Significant differences in the microbiome composition were found among subjects associated with HIV infection, gender, sex behavior, CD4+ T-cell counts, antiretroviral therapy (ART), and the presence of HPV-associated precancerous anal lesions. Results confirm the occurrence of oncogenic viromes in this high HIV-risk population. The oral microbiome in HIV-associated cases exhibited an enrichment of bacteria associated with periodontal disease pathogenesis. Conversely, anal bacteria showed a significant decrease in HIV-infected subjects (Coprococcus comes, Finegoldia magna, Blautia obeum, Catenibacterium mitsuokai). TGW showed enrichment in species related to sexual transmission, which concurs that most recruited TGW are or have been sex workers. Prevotella bivia and Fusobacterium gonidiaformans were positively associated with anal precancerous lesions among HIV-infected subjects. The enrichment of Holdemanella biformis and C. comes was associated with detectable viral load and ART-untreated patients. Metabolic pathways were distinctly affected by predominant factors linked to sexual behavior or HIV pathogenesis. Gene family analysis identified bacterial gene signatures as potential prognostic and predictive biomarkers for HIV/AIDS-associated malignancies. Conclusions: Identified microbial features at accessible sites are potential biomarkers for predicting precancerous anal lesions and therapeutic targets for HIV immunopathogenesis.

The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes

BACKGROUND

According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries.

METHODS

By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics.

RESULTS

Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear.

CONCLUSION

The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.

Closing the gap in education: Raising medical professionals' knowledge and attitudes in transgender health

Transgender and gender diverse (TGD) health is a rapidly evolving, underserviced, and underresearched healthcare field. This chapter will provide a brief review of the research in TGD health and medical education and offer further areas of research and curriculum design.

Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study

BACKGROUND

Although discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating those experiences based on gender identity/expression and related factors has been limited. The aim of this study was to compare the characteristics, experiences, attitude, and expectation toward accessing healthcare service and healthcare providers of transgender women and transgender men in Thailand.

METHODS

A cross-sectional study was conducted from October 2017 to March 2018. The data were collected from transgender women and transgender men aged ≥ 18 years old who lived in Thailand using online platform via different websites and Facebook pages of local transgender group. Binary logistic regression was used to identify the factors related to the study outcomes.

RESULTS

Of 186 transgender people who responded to the questionnaire and were eligible for the study, 73.7% (95% confidence interval [CI] = 66.7-79.8) were transgender women and 26.3% (95% CI = 20.2-33.3) were transgender men. Transgender women were more likely to seek general healthcare from non-traditional healthcare services (crude odds ratio [cOR] = 4.28; 95% CI = 1.55-11.81; P = 0.005), buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18-12.83; P = 0.026), and receive healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42-18.75; P = 0.013) than transgender men. According to the results of applying a multivariable model, transgender respondents who did not know that gender-affirming healthcare services existed in Thailand were more unwilling to receive counseling from gender-affirming healthcare providers than those who did (adjusted odds ratio = 3.70; 95% CI = 1.11-12.36; P = 0.033).

CONCLUSIONS

The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician's supervision. We also found approximately 15% of transgender individuals who did not receive gender-affirming counseling services. Continuing to improve access to care for the transgender community, increasing public relations channels may encourage transgender people to access more healthcare services.

Living in Stealth: A Grounded Theory Study of Transgender Women's Barriers to HIV-Prevention Services and Interventions

Background and Purpose: HIV infection is a health disparity among transgender women. Despite availability of HIV-prevention interventions and services, many transgender women do not access these interventions and services. The purpose of this study was to identify the process by which barriers may prevent transgender women from receiving HIV-prevention interventions and services and to have participants propose ideas on how to overcome these barriers. Methods: Utilizing a grounded theory approach, 25 in-depth, semistructured interviews were conducted with transgender women aged 20-69 years. After providing written informed consent, participants completed an in-depth individual interview. Interviews were audio-recorded and transcribed verbatim. Categories and subcategories were identified from the data using open, axial, and selective coding. Results: A theory grounded in the data named Living in Stealth emerged that described this central phenomenon that underpinned the other main categories of Encountering Social Barriers and Encountering Structural Barriers. Generating Ideas for Restructuring HIV-Prevention for Transgender Women was the final category in which participants provided ideas to overcome HIV-prevention barriers. Implications: Clinicians and researchers providing HIV-prevention services and interventions for transgender women need awareness of the complex nature of HIV prevention for this subpopulation of women. More research is needed to incorporate findings from this study into HIV-prevention interventions for transgender women.

Retention among transgender women treated with dolutegravir associated with tenofovir/lamivudine or emtricitabine in Argentina: TransViiV study

In Argentina, transgender women (TGW) have a high HIV prevalence (34%). However, this population shows lower levels of adherence, retention in HIV care and viral suppression than cisgender patients. The World Health Organization (WHO) recommends the transition to dolutegravir (DTG)-based regimens to reduce adverse events and improve adherence and retention. The purpose of this study was to determine retention, adherence and viral suppression in naïve TGW starting a DTG-based first-line antiretroviral treatment (ART) and to identify clinical and psychosocial factors associated with retention. We designed a prospective, open-label, single-arm trial among ART-naïve HIV positive TGW (Clinical Trial Number: NCT03033836). Participants were followed at weeks 4, 8, 12, 24, 36 and 48, in a trans-affirmative HIV care service that included peer navigators, between December, 2015 and May, 2019. Retention was defined as the proportion of TGW retained at week 48 and adherence was self-reported. Viral suppression at <50 copies/mL was evaluated using snapshot algorithm and as per protocol analysis. Of 75 TGW screened, 61 were enrolled. At baseline, median age was 28 y/o., HIV-1-RNA (pVL) 46,908 copies/mL and CD4+ T-cell count 383 cells/mm3. At week 48, 77% were retained and 72% had viral suppression (97% per protocol). The regimen was well tolerated and participants reported high adherence (about 95%). Eleven of the fourteen TGW who discontinued or were lost to follow-up had undetectable pVL at their last visit. Older age was associated with better retention. DTG-based treatment delivered by a trans-competent team in a trans-affirmative service was safe and well tolerated by TGW and associated with high retention, high adherence and high viral suppression at 48 weeks among those being retained.

"If I'm at home, I do it at home": Qualitative study on HIV self-testing among transgender women in Argentina

BACKGROUND

Evidence among key populations supports acceptability of HIV self-testing (HIVST) due to its privacy and convenience. However, insufficient research has been done among transgender women (TGW), especially in Latin America. Consequently, the aim of this study was to explore the acceptability, perceptions and recommendations for HIVST implementation among TGW in Buenos Aires.

METHODS

A focus group was conducted in July 2019. Particpants were invited to touch and learn about a displayed HIVST kit. The following main topics were explored: acceptability, reasons for seeking self-testing, preferences for training, distribution, periodicity and recommendations for HIVST implementation.

RESULTS

The sample consisted of 12 TGWs; mean age of 26 years (IQR = 22-28); 66% had history of sex-work. The main motivations for seeking HIVST were convenience, privacy, and usage to reduce stigma and discrimination by health-care providers. Recommendations for HIVST were: distribution from primary health centers and trans-sensitive centers; affordable price; assistance by peer health promoters; and the provision of clear written and video instructions.

CONCLUSIONS

Tailored implementation of HIVST can increase HIV testing rates, early detection, and linkage to HIV-care in this high-prevalence group. This study provided community-driven suggestions to inform and adapt an HIVST feasibility pilot study and future implementation in Argentina.

Sociodemographic factors and perceived patient-provider communication associated with healthcare avoidance among women with psychological distress

Objective

To establish the extent to which psychological distress influences health avoidance behavior among women, controlling for patient provider communication and sociodemographic characteristics.

Methods

Data from the 2019 Health Information National Trends Survey (HINTS 5, Cycle 3) was analyzed to obtain healthcare avoidance behavior among women aged 18 and older (n = 2788). Weighted descriptive, bivariate, and multivariable logistic regression models were conducted.

Results

Approximately 649 women or 1 in 4 women (26.7% weighted prevalence; 95% Confidence Interval [CI] 0.23%-0.29%) avoided healthcare in the past 12 months. Non-Hispanic white (62.8%) and married (55.4%) women represented a higher proportion of the sample. Bivariate analysis revealed that the odds of reporting healthcare avoidance among women with mild, moderate, and severe psychological distress (Odds Ratio [OR]: 2.26, 95% CI: 1.45-3.53, p = 0.001; OR: 3.88, 95% CI: 2.29-6.56, p < 0.001; OR: 3.08, 95% CI: 1.81-5.23, p < 0.001) was significantly higher compared to those with none-minimal psychological distress. In the adjusted model, women with moderate and severe psychological distress (Adjusted OR [AOR]:3.15, 95% CI: 1.55-6.38, p = 0.002; AOR: 2.24, 95% CI: 1.10-4.92, p = 0.044) were more likely to report healthcare avoidance than those experiencing none-minimal psychological distress. Furthermore, increasing patient-provider communication score (AOR: 0.91, 95% CI: 0.87-0.96, p < 0.001) reduced the likelihood of healthcare avoidance. Among the sociodemographic variables assessed, being younger (18-49 years) and having less than a high school degree significantly increased the chances of avoiding healthcare.

Conclusion

A high proportion of women with psychological distress avoid necessary healthcare. Patient-provider communication quality, increasing age, and being a high school student contribute to healthcare avoidance in women.

Innovation

Strategies to improve health service utilization must address healthcare avoidance by developing effective health communication targeted at women with psychological distress.

Study protocol: navigating access to gender care in Ireland-a mixed-method study on the experiences of transgender and non-binary youth

INTRODUCTION

There has been a global increase in demand for gender-specific healthcare services and a recognition that healthcare access is complex and convoluted, even in countries with well-developed healthcare services. Despite evidence in Ireland supporting the improvement in physical and mental health following access to gender care, little is known about the local healthcare navigation challenges. Internationally, research focuses primarily on the experience of service users and omits the perspective of other potential key stakeholders. Youth experiences are a particularly seldom-heard group.

METHODS AND ANALYSIS

This study will use a sequential exploratory mixed-methods design with a participatory social justice approach. The qualitative phase will explore factors that help and hinder access to gender care for young people in Ireland. This will be explored from multiple stakeholders' perspectives, namely, young people, caregivers and specialist healthcare providers. Framework analysis will be used to identify priorities for action and the qualitative findings used to build a survey tool for the quantitative phase. The quantitative phase will then measure the burden of the identified factors on healthcare navigation across different age categories and gender identities (transmasculine vs transfeminine vs non-binary).

ETHICS AND DISSEMINATION

This study has been approved by St Vincent's Hospital Research Ethics Committee (RS21-019), University College Dublin Ethics Committee (LS-21-14Kearns-OShea) and the Transgender Equality Network Ireland's Internal Ethics Committee (TIECSK). We aim to disseminate the findings through international conferences, peer-review journals and by utilisation of expert panel members and strategic partners.

Examining Factors Associated with Gender Identity Among Individuals Disengaged from HIV Care in Argentina

BACKGROUND

Transgender women (TGW) consistently show lower adherence to antiretroviral treatment (ART), than cisgender people (CP) living with HIV. This study examined sociodemographic and psychosocial factors associated with gender identity among individuals disengaged from HIV care in Argentina.

METHODS

Data for this study was obtained at baseline from the Conexiones y Opciones Positivas en la Argentina 2 (COPA2) study. Forty-one TGW and 360 CP (177 male, 183 female) disengaged from HIV care completed questionnaires assessing sociodemographic information, severity of depressive symptoms, substance and alcohol use, patient-provider relationship quality, self-efficacy, ART adherence motivation, self-reported adherence, and treatment-related factors. Analyses included chi-square tests exploring the association between categorical variables and gender identity, and ANCOVAs comparing groups controlling for age.

RESULTS

Being a TGW was associated with having only public health insurance; substance use, particularly cocaine; substance-related problems; and hazardous drinking. TGW showed more negative consequences related to substance use, more hazardous alcohol use, lower patient-provider relationship quality, and lower self-reported adherence, than CP.

CONCLUSIONS

Harm reduction should be a key component in HIV care for TGW to address substance use. Health care teams should receive formal training in patient-provider communication skills and trans-specific competencies to enhance TGW's adherence and retention. Public policies to address structural factors that negatively affect TGW's adherence to ART are also needed.

Health Impact of Stigma, Discrimination, Prejudice, and Bias Experienced by Transgender People: A Systematic Review of Quantitative Studies

Introduction: Stigma affects all aspects of transgender peoples' health. The purpose of this systematic review is to summarize the quantitative findings from the literature focused on the health impact of stigma resulting from discrimination, prejudice, and bias experienced by transgender people.Method: To better understand the current state of the health impact of transgender stigma, the author conducted a search that included stigma, discrimination, prejudice, bias, health, and transgender people.Results: A total of 15 studies met inclusion criteria for review. Results indicate that transgender people experience discrimination, prejudice, and bias at high levels. When internalized, this victimization leads to decreased psychological health, including increased harmful behaviors such as substance abuse and eating disorders, reduced relationship quality, ineffective coping and lower levels of self-esteem, and increased risk of attempted suicide. Internalized stigma also leads to decreased physical health outcomes stemming from healthcare avoidance, reduced healthcare utilization, decreased screenings, and delayed treatment.Discussion: Additional research is needed to enhance generalizability to larger transgender populations. Additional studies are also required to increase provider knowledge and cultural competence to provide safe care environments and transgender-appropriate care. As well, further research is vital to incorporate LGBTQ-sensitive training in healthcare academia.

Health Problems & Barriers to Healthcare Services for the Transgender Community in Lahore, Pakistan

Objectives:

To find out the major health problems and barriers in getting health care by transgender community in Lahore, Pakistan.

Methods:

An analytical cross-sectional study was conducted in transgender community of Lahore from January to October 2020. The study included 214 participants from different areas of Lahore by targeting their “gurus”. Non-probability, snow-ball sampling technique was used to collect required sample size. Data was collected by using a structured questionnaire. Data were analyzed using SPSS version 23. Results were generated in form of tables and graphs. Chi square test and Fischer’s exact test were used to find out associations between health seeking behavior with their transgender status and p value was fixed as ≤ 0.05 as significant.

Results:

Among total 214, 78.5% were transgender females and 21.5% were transgender male. Among the common health problems were depression (56%), anxiety (59%) and genital tract ulcers (45%). About 70% transgender seek health care from government hospitals. Among total 214 participants, 70% reported that they receive poor quality of health care. The main reasons of not getting proper care is non acceptance (20.7%), feeling ashamed (28.7%), non-availability of CNIC (44.5%) and un-affordability (6.1%). Significant association of transgender female with consultation with doctors (p=0.013), seeking care at government hospitals (p =0.038) poor experience at health care facility (0.050), neglect during medical treatment (p=0.015) and feeling of discrimination during treatment (p= 0.042).

Conclusion:

Transgender community face physical, mental, social and reproductive health issues. About 70% trans-genders receive poor quality of health care services. Non acceptance, feeling ashamed, non-availability of CNIC and non-affordability have been reported as major barriers in getting desired health care.

[Psychometric Properties of the Scale of Negative Attitudes Towards Trans People in Healthcare Providers in Puerto Rico]

The ignorance towards the Trans people can cause healthcare providers to assume negative attitudes towards this population. It is relevant to understand with more amplitude the manifestations of stigma towards the Trans population using instruments whose psychometry is adequate. The main objective of the present study was to evaluate the reliability of the Scale of Negative Attitudes towards Trans People (EANT, in Spanish) and its factorial structure in healthcare providers in Puerto Rico. As a secondary objective, differences in attitudes towards Trans people between physical healthcare providers and mental healthcare providers were evaluated. The sample consisted of 67 healthcare providers recruited according to their availability. A point-biserial correlation, a Cronbach's alpha analysis, a Confirmatory Factor Analysis (CFA), and the non-parametric Mann-Whitney test were carried out to examine our objectives. The results confirmed that the EANT has a one-dimensional structure. The Cronbach's alpha internal consistency index of the scale was .75. No significant differences were found in attitudes towards Trans people between physical healthcare providers and mental healthcare providers. Finally, a discussion of the research findings is presented, as well as its limitations and contributions.

Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography

Objective

Transgender and non-binary individuals frequently engage with healthcare services to obtain gender-affirming care. Little data exist on the experiences of young people accessing gender care. This systematic review and meta-ethnography aimed to identify and synthesise data on youths’ experiences accessing gender-affirming healthcare.

Method

A systematic review and meta-ethnography focusing on qualitative research on the experiences of transgender and non-binary youth accessing gender care was completed between April-December 2020. The following databases were used: PsychINFO, MEDLINE, EMBASE, and CINAHL. The protocol was registered on PROSPERO, international prospective register of Systematic Reviews (CRD42020139908).

Results

Ten studies were included in the final review. The sample included participants with diverse gender identities and included the perspective of parents/caregivers. Five dimensions (third-order constructs) were identified and contextualized into the following themes: 1.) Disclosure of gender identity. 2.) The pursuit of care. 3.) The cost of care. 4.) Complex family/caregiver dynamics. 5.) Patient-provider relationships. Each dimension details a complicated set of factors that can impact healthcare navigation and are explained through a new conceptual model titled “The Rainbow Brick Road”.

Conclusion

This synthesis expands understanding into the experience of transgender and non-binary youth accessing gender-affirming healthcare. Ryvicker’s behavioural-ecological model of healthcare navigation is discussed in relation to the findings and compared to the authors’ conceptual model. This detailed analysis reveals unique insights on healthcare navigation challenges and the traits, resources, and infrastructure needed to overcome these. Importantly, this paper reveals the critical need for more research with non-binary youth and research which includes the population in the design.

“We’re all in an abusive relationship with the health-care system”: Collective memories of transgender health care

Collective memory work allows participants to recall, examine, and analyze their memories and experiences within a broader cultural context to see how their individual experiences link to collective, shared experiences of similar and/or different groups. This study utilized collective memory work to engage six trans participants in an examination of their individual experiences with health care. During a four-hour focus group, participants engaged in this process of discourse analysis and came to collective agreements about the meaning of their stories, the intentions of the author, and the intentions of others in their shared lived experience. In this paper, we will provide a thorough and rich description of the participants’ memories and their collective analysis, which highlights the interconnection between perceptions of oneself and their experiences with the health-care system. Our analysis revealed participants felt they had a toxic relationship with the health-care system. In particular, they discussed how health-care professionals left trans people tremulously asking for services, uncertain if they would receive care, what the quality of the care would be, and whether they would be treated respectfully. When discussing positive health-care experiences, participants highlighted when fears and anxieties were not realized, but all instances reflected some inappropriate actions. The results from this study will contribute to research on trans health care by providing a nuanced understanding of how health-care experiences impact trans communities collectively, as well as the ways in which health practices can be improved.

Cisgenderism and transphobia in sexual health care and associations with testing for HIV and other sexually transmitted infections: Findings from the Australian Trans & Gender Diverse Sexual Health Survey

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of 'gender insensitivity', which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.

Mental health, substance use, experiences of violence, and access to health care among transgender and non-binary people during the COVID-19 lockdown in Argentina

Background: Lockdown measures are effective to control COVID-19 spread; however, concerns have increased regarding its impact on transgender and non-binary people. Aims: This study describes self-reported changes in mental health, substance use, experiences of violence, and access to health care and basic services among transgender and non-binary population from Argentina after two months of implementation of the lockdown. Methods: An online national survey was responded by 182 participants (72 transfeminine [TF], 66 transmasculine [TM], 44 non-binary [NB] people) between May and June 2020. The questionnaire was informed by the results of focus groups, reviewed by activists, and disseminated through social media. Descriptive statistics were used to summarize data. Results: The COVID-19 pandemic and the lockdown have had a general negative impact on the participants. TF participants reported a greater proportion of negative changes in the socioeconomic aspect, such as reduction in income and barriers to access basic services (housing, food, hygiene products and financial assistance). TM and NB participants reported higher proportions of adverse psychological impact, with high frequencies of intense negative emotions and suicidal ideation. A general reduction in substance use was observed in the three groups. The most frequent source of violence in the three groups was from a family member, especially among NB participants. Half of the TF and TM individuals reported difficulties to access or continue their hormone therapy. TM and NB participants reported considerable barriers to access mental health care. Conclusion: The COVID-19 pandemic and the prolonged lockdown have had a negative impact on the transgender and NB population, aggravating their preexisting situation of vulnerability and exclusion. Furthermore, this impact affected each subgroup differently in a particular and specific way.

Breast Cancer Risk and Screening in Transgender Persons: A Call for Inclusive Care

The Society of Surgical Oncology is committed to reducing health disparities adversely affecting sexual and gender minorities. Transgender persons represent a socially disadvantaged group who frequently experience discrimination and receive disparate care, resulting in suboptimal cancer outcomes. The rate of breast cancer development in transgender individuals differs from rates observed in their cisgender counterparts, however there is little evidence to quantify these differences and guide evidence-based screening and prevention. There is no consensus for breast cancer screening guidelines in transgender patients. In this review, we discuss barriers to equitable breast cancer care, risk factors for breast cancer development, and existing data to support breast cancer screening in transgender men and women.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

Does Discrimination Affect Whether Transgender People Avoid or Delay Healthcare?: A Nationwide Cross-sectional Survey in South Korea

This study examined the association between perceived discrimination and healthcare avoidance and delay (HAD) among transgender adults in South Korea (hereafter Korea). We conducted a nationwide cross-sectional survey of 244 Korean transgender adults in 2017. Discrimination within the last 12 months was categorized into four groups based on the reason(s) of discrimination experienced: (1) 'never experienced' discrimination, (2) 'only due to transgender identity,' (3) 'due to reason(s) other than transgender identity,' and (4) 'due to both transgender identity and other reason(s).' Korean transgender adults who experienced discrimination 'only due to transgender identity' and 'due to both transgender identity and other reason(s)' reported 1.91-times (95% CI 1.02-3.55) and 1.96-times (95% CI 1.32-2.92) higher prevalence of past 12-month HAD, respectively, than those who had no such experiences. Our findings suggest that institutional efforts are needed to protect transgender people from discrimination, which can contribute to improved access to healthcare among transgender populations in Korea.

Acceptability of dual HIV/syphilis rapid test in community- and home-based testing strategy among transgender women in Buenos Aires, Argentina

BACKGROUND

Little is known of acceptability and feasibility of dual HIV and syphilis rapid tests in community- and home-based provider-initiated strategies among transgender women (TGW), in Latin America. Objectives were (1) to assess the acceptability of this strategy and, (2) to determine the percentage of positive results of HIV and syphilis, analyze the correlates of HIV or syphilis positive results, and measure the rates of effective referral and treatment completion among TGW.

METHODS

A multidisciplinary team tested 89 TGW in Buenos Aires. An acceptability survey was administered after the HIV/syphilis Duo test was used. All confirmed cases were referred for treatment initiation.

RESULTS

We found high levels of acceptability (98.8%) of this strategy among TGW. However, only 60.7% preferred simultaneous HIV and syphilis diagnosis test. Moreover, we found 9% of positive results of HIV, 51.7% of syphilis, and 3.4% of positive results for both infections. Only not being tested before was associated with an HIV positive result, and only low level of education was associated with a positive syphilis result. Among 8 TGW who tested positive for HIV, 37.5% (n = 3) started antiretroviral therapy. Of 46 who tested positive for syphilis, only 73.9% (n = 34) were effectively referred and from 23 who started treatment, only 39.1% completed it.

CONCLUSIONS

Community- and home-based dual HIV and syphilis rapid test is a feasible and highly acceptable approach for this hard-to-reach population. Implementing similar strategies could improve screening uptake and accessibility. However, these results highlight the need to improve strategies for treatment uptake, in order to reduce morbidity and risk of onward transmission.

Reduction of Gender Identity Stigma and Improvements in Mental Health Among Transgender Women Initiating HIV Treatment in a Trans-Sensitive Clinic in Argentina

Purpose: Stigma toward transgender women (TGW) increases psychosocial vulnerability, leading to poor mental health and affecting access and retention in HIV care. Trans-sensitive health care (TSHC) has the potential to mitigate this adverse impact. This study aimed to describe baseline characteristics in gender identity stigma (GIS), mental health, and substance use among TGW living with HIV initiating antiretroviral treatment and to analyze changes after 6 months in HIV care in a TSHC clinic in Argentina. Methods: Sixty-one TGW living with HIV responded to the following questionnaires at baseline and after 6 months in TSHC: sociodemographic, experiences of GIS (in health care, police, etc.), Center for Epidemiologic Studies Depression Scale (CES-D) (depression), State Trait Anxiety Inventory (STAI) (anxiety), Drug Abuse Screening Test (DAST-10) (drug use), Alcohol Use Disorders Identification Test (AUDIT) (alcohol use), 8-item Personal Wellbeing Index-Adults (PWI-A) (quality of life [QOL]), Personality Inventory for DSM-5-Brief Form (PID-5-BF) (maladaptive personality traits), and Duke Index (social support). Analyses included Pearson correlations to analyze associations between variables; and paired sample t-tests, to explore changes between baseline and 6 months. Results: A significant proportion experienced episodes of GIS the last year in any context. At baseline, 50.8% showed significant depressive symptoms and 65.6% reported any drug use in the last year. At 6 months, participants experienced a significant reduction of GIS, both enacted and internalized, anxiety, drug, and alcohol use, and improvement in QOL. The remaining mental health indicators were not significantly modified. Conclusion: A TSHC service may have a gender-affirmative impact on TGW initiating HIV care that contributes to reduce GIS and substance use and improve mental health. This highlights the importance that HIV care programs for TGW comply with trans-sensitive essential components to enhance retention.

Perspectives and Experiences of Transgender and Non-binary Individuals on Seeking Urological Care

OBJECTIVE

To describe perspectives and experiences related to urology care-seeking of transgender and non-binary (TGNB) individuals assigned male at birth.

MATERIALS AND METHODS

This HIPAA-compliant study was IRB approved and followed Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines. Through semistructured interviews, perspectives, and experiences of individuals related to urology care-seeking were explored. Open-ended questions were designed to elicit a range of responses rather than quantifiable data. Thematic codes were developed and explicitly defined. Codes pertaining to patient experiences were assessed and described.

RESULTS

Twenty-five TGNB individuals assigned male at birth were interviewed. Participants reported an array of factors that informed and inhibited care-seeking, factors that framed individual urologic care experiences, and their overall impression of the healthcare system's ability to effectively and respectfully serve the TGNB population. Specifically, participants reported that prior negative healthcare experiences dissuaded them from seeking care such as feeling discriminated against and having a lack of trust in providers. Additionally, participants reported feeling a need and responsibility to "educate" providers on both their medical needs and psychosocial experiences. Participants were also unclear how best to identify "trans-friendly" urologists who are culturally competent and have appropriate medical knowledge.

CONCLUSION

TGNB individuals face significant barriers to care for unique healthcare needs. TGNB participants described care avoidance and reported experiences of healthcare discrimination. These data highlight the importance for urologists to understand the perspectives and historical experiences of these individuals who may seek urological care.

How to adapt sexual and reproductive health services to the needs and circumstances of trans people- a qualitative study in Colombia

BACKGROUND

People living a trans-life require access to equitable healthcare services, policies and research that address their needs. However, trans people have experienced different forms of violence, discrimination, stigma, and unfair access barriers when dealing with healthcare providers. Therefore, adapting sexual and reproductive health services with the purpose of providing more equitable, inclusive and discrimination-free healthcare services is an urgent need. The article presents an example of how operative research can be used in order to adjust sexual and reproductive healthcare services to trans people's needs, identities and circumstances.

METHODS

This is a qualitative study written from a constructivist perspective, and it is based on the voices and experiences of trans people in four major cities in Colombia. The research used a combination of focus groups of discussion (n = 6) and in-depth interviews with trans people (n = 13) in Barranquilla, Bogota, Cali and Medellin. This research had two specific objectives: i) identifying the main sexual and reproductive health needs of people living a trans-life; and ii) generating new evidence in order to guide the adaptation of sexual and reproductive health services centered to trans people's needs, identities, and circumstances. Qualitative data codification and analysis was using NVivo.

RESULTS

Once access barriers to sexual and reproductive health services, unmet sexual and reproductive health needs were identified, the research helped define strategies to adapt sexual and reproductive health services to the needs, identities, and circumstances of people living a trans-life in Colombia. Amongst the main barriers found were healthcare costs, lack of insurance, stigmatization, discrimination and abuse by health care providers. Perhaps among the most notable sexual and reproductive health needs presented were trans-specific services such as sensitive assistance for the transition process, endocrinology appointments, and sex reaffirmation surgeries.

CONCLUSIONS

The evidence obtained from this research allowed Profamilia, a Colombian healthcare provider, to adapt the sexual and reproductive health services it provides to people living a trans-life in Colombia. Furthermore, it was possible for Profamilia to design and implement an inclusive sexual and reproductive health program that specifically addresses trans people's needs, identities, and circumstances.

Voice And Gender Incongruence: Relationship Between Vocal Self-Perception And Mental Health Of Trans Women

OBJECTIVE

To verify the association between vocal perception and Common Mental Disorders (CMD) suspicion in trans women.

METHODS

Cross-sectional observational study including 24 adult trans women with a minimum time of presentation as a woman of six months. The sampling of the subjects was supported by the "Snowball" technique. Three questionnaires were applied for data collection: sociodemographic and health data, Self-Reporting Questionnaire (SRQ-20) and Trans Woman Voice Questionnaire (TWVQ). The sociodemographic and health data collected were: age, marital status, education, smoking habits, speech therapy, use of hormones, and whether they had undergone Sex Reassignment Surgery (SRG). SRQ-20 was used for suspicion of CMD evaluation, such as depressive and anxiety symptoms. TWVQ is a vocal self-report questionnaire for trans women living the full-time gender role in which they self-identify. TWVQ has a minimum score of 30 points and a maximum of 120 points. Higher scores are associated with perceptions of a higher frequency of voice-related difficulties and psychosocial impacts. For statistical analysis, data were analyzed descriptively and statistically using Fisher's and Mann-Whitney's exact tests, both with a significance level of 5%.

RESULTS

The average participants' age in this study was 28.2 years old (SD = 6.5 / minimum = 21 and maximum = 48); 83.3% were single; most (41.7%) were high school graduates; and most (95.83%) had not undergone Sex Reassignment Surgery. All subjects reported using hormones; 37.5% were smokers; 4.2% had undergone speech therapy; and the average number of years of experience in the female role was 8.8 years (SD = 7.2). The average TWVQ score was 55.4 points (SD = 4.3). Through SRQ-20, it was verified the prevalence of suspected CMD in 58.3% of the participants. The study results indicated that communicative dissatisfaction in trans women due to inconsistent voice with the recognized gender is associated with probable CMD such as depression and anxiety (P= 0.001).

CONCLUSION

Trans women who reported greater difficulties and voice-related effects in their lives had more symptoms of anxiety and depression. Although more research is needed, results indicate the need for inter-professional preventive and therapeutic actions directed towards assisting trans women. This fact encourages reflection on the care of this population and the role of health professionals, enhancing scientific production, clinical practice and the inclusion of the "transsexuality" theme in Speech Language and Hearing Sciences.

Transgender women's satisfaction with healthcare services: A mixed-methods pilot study

BACKGROUND

Many transgender women are dissatisfied with healthcare services PURPOSE: (a) To describe satisfaction/dissatisfaction with healthcare services; and (b) to describe barriers/facilitators of satisfaction with healthcare services among a sample of transgender women.

DESIGN AND METHODS

A mixed methods design collected quantitative data (n = 50) and qualitative data (n = 25) from transgender women.

FINDINGS

Quantitatively, satisfaction with healthcare services was high among the participants, with lower areas related to healthcare systems issues. Qualitatively, participants identified barriers and facilitators of healthcare satisfaction.

IMPLICATIONS

This study provides clinical, research, educational, and policy implications for improving healthcare satisfaction among transgender women.

Gender identity and sexual behavior stigmas, severe psychological distress, and suicidality in an online sample of transgender women in the United States

PURPOSE

The objective of this study is to (1) quantify burden of perceived, anticipated, and enacted gender identity (GI) and sexual behavior (SB) stigmas and (2) explore associations between GI and SB stigmas with key mental health factors among transgender women in the United States.

METHODS

We estimated associations between GI and SB stigmas with severe psychological distress, suicidal ideation, and suicide attempt using cross-sectional data from the Transgender Women's Internet Survey and Testing study from March to April, 2019. Modified Poisson regression produced prevalence ratios and 95% confidence intervals for severe psychological distress, suicidal ideation, and suicide attempt with GI and SB stigma items individually, as well as the GI and SB stigma items treated as two scales.

RESULTS

Of 381 transgender women, 52% experienced severe psychological distress in the past month, whereas 59.3% and 13.12% reported suicide ideation and attempt in the past year, respectively. In adjusted models, GI and SB stigma scales were significantly, positively associated with severe psychological distress, suicidal ideation, and suicide attempt.

CONCLUSIONS

Continued training for providers in trans-competent mental health care and the development of newer engagement and delivery strategies for stigma mitigation interventions are needed.

"They feel empowered to discriminate against las chicas": Latina transgender women's experiences navigating the healthcare system

BACKGROUND

Transgender Women of Color are more likely to experience oppression at the hands of healthcare providers than their transgender White counterparts. However, there is a paucity of research on the experiences of Latina transgender women in the United States.

AIMS

Using an intersectionality theory framework, the present study aimed to investigate the factors that contribute to Latina transgender women's decision to seek or refuse healthcare services and Latina transgender women's experiences with healthcare providers in the United States.

METHODS

A community sample of 15 Latina transgender women at a large metropolitan city in Florida participated in a focus group to explore their experiences with seeking out and accessing healthcare services.

RESULTS

Thematic analysis revealed five themes: 1) experiences in seeking healthcare, 2) the effects of hormones on mental health, 3) resistance, 4) imparting collective knowledge, and 5) recommendations to healthcare providers.

CONCLUSIONS

Through collective dialog these women gave voice to their needs and pains in the context of healthcare while also positioning themselves as agentic, resistant, and aware of the power of collectivism in the process of healing. The current findings support and extend calls for training improvements related to transgender populations, giving voice not only to the need for training but specifying immigrant Latina transgender women's desire for such training. Also, elements related to Latinx cultural values (e.g., convivencia, familismo) must be considered when working with Latina transgender women.

Work and health issues of the transgender population: factors associated with entering the labor market in the state of São Paulo, Brazil

The transgender population encounters several barriers in entering the labor market, whichfurther impacts their health. In this cross-sectional study, the factors associated with their insertion in the formal job market were analyzed. Participants were recruited in seven municipalities of the state of São Paulo between 2014 and 2015. Logistic regression was used to estimate the odds ratios (OR) of the association between formal insertion and selected characteristics. We included 672 individuals, of which 82.3% were working, 13.1% were not employed, and 4.6% were not in the labor market. Among those working, only 16.7% were in the formal labor market. Factors independently associated with formal employment were: being atrans man, having 12 years or more of education, being under follow-up for gender transition procedures in the healthcare services, having private health insurance, and never having been arrested. Our results highlightpart of the obstacles the transgender population has toovercome to enter the labor market, and point to the need for public policies specifically designed for the transgender population aiming to reduce school dropout and expand access to comprehensive health care, thereby reducing theirvulnerability.

Gender-Based Violence Against Transgender People in the United States: A Call for Research and Programming

Gender-based violence (GBV) is an umbrella term for any harm that is perpetrated against a person's will and that results from power inequalities based on gender roles. Most global estimates of GBV implicitly refer only to the experiences of cisgender, heterosexually identified women, which often comes at the exclusion of transgender and gender nonconforming (trans) populations. Those who perpetrate violence against trans populations often target gender nonconformity, gender expression or identity, and perceived sexual orientation and thus these forms of violence should be considered within broader discussions of GBV. Nascent epidemiologic research suggests a high burden of GBV among trans populations, with an estimated prevalence that ranges from 7% to 89% among trans populations and subpopulations. Further, 165 trans persons have been reported murdered in the United States between 2008 and 2016. GBV is associated with multiple poor health outcomes and has been broadly posited as a component of syndemics, a term used to describe an interaction of diseases with underlying social forces, concomitant with limited prevention and response programs. The interaction of social stigma, inadequate laws, and punitive policies as well as a lack of effective GBV programs limits access to and use of GBV prevention and response programs among trans populations. This commentary summarizes the current body of research on GBV among trans populations and highlights areas for future research, intervention, and policy.

Home-based HIV testing: Using different strategies among transgender women in Argentina

BACKGROUND

In Argentina, HIV prevalence among transgender women (TGW) has been reported at 34%. The stigma is one of the most important factors limiting their access to healthcare services. The aims of this study were to compare different HIV testing methodologies, to determine the factors associated with HIV diagnosis and to determine the feasibility of a home-based HIV testing service for TGW.

METHODS

A multidisciplinary team performed home-based HIV testing interventions in four cities of Argentina. Participants self-identified as TGW, older than 14 years and with a negative or unknown HIV status. Blood samples were screened by two rapid tests (RT), one based on antibodies (Determine™ HIV-1/2) and the other on antigen and antibodies (Determine™ HIV-1/2 Combo), and the subsequent blood processing via 4th generation ELISA (VIDAS HIV DUO). All reactive samples were confirmed with a viral load (VL). We compared the results of both RT with the ELISA. Samples were pooled in groups of 6 and a VL (Abbott Real Time) performed to identify acute HIV infections. Factors associated with HIV infection were evaluated with multivariate logistic regression analysis.

RESULTS

A total of 260 TGW were tested, 51 tested positive (HIV prevalence 19.6%). There were no discordant results between both RTs nor between RTs and 4th generation ELISA, therefore the correlation was 100%. The VL identified 2 additional positive samples. The final analytic sample for positive cases consisted of 53 TGW. In the multivariate analysis, factors associated with a positive HIV result were history of other sexually transmitted infections (STIs) and not being previously tested for HIV. TGW tested for the first time were at 4 times greater risk of being HIV positive compared to those that were tested previously.

CONCLUSIONS

A multidisciplinary home-based HIV testing service among TGW is feasible and effective to detect cases of HIV infection. The testing algorithm should start with an RT followed by molecular diagnosis. The history of STIs and never having been tested for HIV were the factors associated with HIV-positive results and should determine efforts to reach this population. Home-based testing reaches individuals that were not tested before and who have more risk of acquiring HIV.

Social Network Organization, Structure, and Patterns of Influence Within a Community of Transgender Women in Lima, Peru: Implications for Biomedical HIV Prevention

Understanding social network structures can contribute to the introduction of new HIV prevention strategies with socially marginalized populations like transgender women (TW). We conducted 20 semi-structured interviews and four focus groups (n = 32) with TW from selected social networks in Lima, Peru between May and July, 2015. Participants described layers of social influence from diverse actors in their social networks. The majority identified a close relative as their primary social support, with whom they confided secrets but avoided issues of transgender identity, sexuality, and sex work. Participants described close circles of TW friends with whom they shared information about gender identity, body modification, and sexual partners, but avoided issues like HIV. Community leadership included political leaders (who advocated for transgender rights) as well as social leaders (who introduced TW to hormone therapy, body modification, and commercial sex). Detailed analysis of TW social networks can contribute to implementation and acceptability of new HIV prevention technologies.

A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients

PROBLEM DEFINITION

Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking.

INITIAL APPROACH

The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels.

NEXT STEPS

The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide.

CONCLUSION

In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.