Sex Workers, Fem Queens, and Cross-Dressers: Differential Marginalizations and HIV Vulnerabilities Among Three Ethnocultural Male-to-Female Transgender Communities in New York City

The Health Needs of Sexual and Gender Minority Migrant Women in the United States: A Scoping Review

Purpose: This scoping review characterizes the peer-reviewed evidence on the health of first-generation sexual and gender minority (SGM) migrant women to the United States and identifies research gaps and future priorities. Methods: On February 1, 2022, the following databases were searched: PubMed (MEDLINE), Embase, CINAHL Plus with Full Text, APA PsycINFO, and PAIS Index. Primary research studies based in the United States, in English, on first-generation SGM migrants (i.e., immigrants, refugees, asylum seekers) were included. Gray literature and review articles were excluded. Health outcome data were not extracted from nonbinary populations nor transgender men. Themes were generated using qualitative content analysis. Results: Thirty-three studies were reviewed, most were qualitative, and 11 focused on transgender women migrants (especially from Latin America), while only one was exclusively on sexual minority women (SMW) migrants. Premigration experiences of violence and discrimination were linked to high prevalence rates of post-traumatic stress disorder, depression, and anxiety. Postmigration stressors included lack of educational and employment opportunities, reduced access to social services, and experiences of stigma and discrimination, which were also associated with the development of depressive symptoms. Transgender women migrants reported not seeking formal medical care, given a lack of gender-affirming services and insurance resulting in reliance on unsafe informal care networks for hormone therapy and feminization procedures. Conclusion: Future interventions should focus on fostering social support networks of SGM migrant women to help improve their mental health outcomes. Research priorities should include studies on SMW migrants and more quantitative research that could identify additional health needs (i.e., sexual health) of SGM migrant women.

A Descriptive Account of the Nature and Extent of Transgender Homicide in America, 2010 to 2021

There is a growing acknowledgment of transgender homicide as a serious social and public health issue; indeed, the American Medical Association has even referred to violence against transgender people as an "epidemic." Addressing this issue, however, requires understanding the patterns associated with this violence. Yet, reliable data for doing so does not currently exist, especially in recent years. As such, the prevalence of these incidents and their key features are not easily understood. The current study addresses this issue using a comprehensive nationwide database on 305 instances of homicide directed against transgender people between 2010 and 2021, collected through extensive open-source data collection methods. The descriptive analyses of these incidents demonstrate pronounced increases in homicide victimization over time, and clear geographic clustering by state, such that roughly one in four incidents occurred in just three states: Texas, Florida, and California. After accounting for the estimated size of the transgender population, Louisiana, Mississippi, and Missouri emerge as the most dangerous states with the highest risk of homicide victimization. The results also clearly demonstrate the intersectional nature of transgender homicide, in finding that most homicide victims are young Black or Hispanic transgender women. We conclude by emphasizing the need for multipronged policy responses to this issue that recognize the uniquely dangerous intersection of social problems that contribute to the vulnerable social position of many transgender people, including their vulnerability to homicide victimization.

Transgender and Gender Diverse (TGD) Asian Americans in the United States: Experiences of Violence, Discrimination, and Family Support

Transgender and gender diverse (TGD) Asian Americans in the U.S. have multiple stigmatized identities, yet their experiences of violence and discrimination are not well understood. We utilized the 2015 United States Trans Survey, the largest survey to date with U.S. TGD people, to study the experiences of TGD Asian Americans. Our study included 699 TGD Asian Americans who experienced violence and discrimination in the form of unequal treatment, verbal harassment, and physical attack. We assessed how experiences differed by sociodemographic characteristics, including birthplace, income, age, education, disability, gender identity, and region. We also explored how family support was associated with experiences of violence in the sample. Bivariate analyses and multivariable regressions were used to understand how sociodemographic variables and family support are linked to experiences of violence and discrimination. Results indicated that income, age, disability, gender identity, and family support are significantly associated with violence and discrimination. As TGD Asian Americans currently experience high levels of violence and discrimination due to transphobia and a rapidly rising anti-Asian bias stemming from the COVID-19 pandemic, efforts to better understand factors that may increase vulnerability and identify how family support can mitigate those experiences are imperative.

A Scoping Review of Health Outcomes Among Transgender Migrants

Purpose

Transgender people constitute diverse populations who experience a range of adverse health outcomes. Despite increasing awareness of adverse health outcomes among migrant populations, there has been a dearth of studies focused on the health of transgender migrants. The goal of this scoping review was to describe common themes and empirical trends in research on the health of transgender migrants and identify gaps for future research and programming.

Methods

Using a systematic review protocol, we searched PubMed, Embase, Scopus, PsycINFO, CINAHL, and Web of Science with a combination of terms to identify empirical articles that examined health outcomes among transgender migrants. The search included studies published as of May 2019.

Results

Twenty of 1666 identified records met inclusion criteria. All studies were cross-sectional, and 50% were quantitative designs, 45% were qualitative designs, and 5% were mixed-methods designs. The majority reported on sexually transmitted infections (55%), violence (40%), and mental health (35%). Qualitative studies were generally high quality, while many quantitative studies had high risk of bias. While some adverse health outcomes may abate, stigmatizing social conditions continue to impact transgender migrant's health postmigration.

Conclusions

Anti-transgender and anti-immigrant stigma may contribute to adverse health outcomes for transgender migrants. Additional research using rigorous inclusive methods to survey a broader range of health domains is needed. The lives of transgender migrants are continuously upended by oppressive policies; therefore, it is vital to continue to expand the breadth of transgender health research.

HIV Care Engagement Among Trans Women of Color in San Francisco Bay Area Demonstration Projects: Findings from the Brandy Martell Project and TransAccess

In the San Francisco Bay Area (SFBA), trans women of color are disproportionately affected by HIV and have poor HIV care outcomes. The Brandy Martell Project and TransAccess were two demonstration projects aimed at increasing HIV care engagement and retention among trans women of color in the SFBA. Both projects took place in clinics with a long history of providing trans health care and social services. Both also relied on peer navigation to address systems barriers and promote HIV care linkage and engagement. Our analysis was to identify associations between intervention exposure and primary HIV care visits, ART prescription, and retention in HIV care. Using GEE, we estimated the association between intervention exposure measures (receipt of intervention, intervention dose, intervention provider, and peer dose) and any primary HIV care visit or ART prescription over the 12-month period. Overall, the Brandy Martell Project and TransAccess interventions had significantly positive associations with HIV care outcomes measured. Peer navigation also had a significantly positive association with HIV care outcomes. These interventions demonstrate promise for engaging and retaining trans women of color in HIV care, and call for future investment in this highly underserved community.

Thick trust, thin trust, social capital, and health outcomes among trans women of color in New York City

Introduction: Many trans women of color communities experience high HIV seroprevalence, extreme poverty, high rates of victimization and substance use, and poor mental health. Greater knowledge of trans women of color social capital may contribute toward more effective services for this marginalized population. Methods: These data come from a mixed-methods study that examined trans/gender-variant people of color who attended transgender support groups at harm reduction programs in NYC. The study was conducted from 2011 to 12, total N = 34. The qualitative portion was derived from six focus group interviews. Results: Two support groups stood out as exhibiting very strong alternative kinship structures. One group was comprised of immigrant trans Latinas, and the other group were trans women of African descent living with HIV. Both groups demonstrated ample cultivation of "trust capital" in the form of "thick trust" (bonding capital) and "thin trust" (bridging/linking capital) both inside and outside/beyond the support groups. Thick trust included the cultivation of intimacy, support in primary romantic relationships, and community leadership. Thin trust included networking with a variety of organizations, increased educational opportunities, and cultural production. Discussion: Participants "opened up to social capital" through the process of trusting as a series of (1) risks; (2) vulnerabilities; and (3) reciprocities. A solid foundation of thick trust resulted in a social, psychological, and emotional "base." Upon this foundation, thin trust was operationalized resulting in positive material, economic, and quality-of-life outcomes, leading to an expanded space of capabilities.

Labor of love: The formalization of care in transgender kinship organizations

While prior research shows how community-based organizations (CBO’s) create new social ties and solidarities, we know less about CBO’s that formalize preexisting relationships of care. Analyzing transgender nonprofits as a strategic case, this article develops the concept of kinship organizations: organizations that incorporate norms, networks, and resources from kinship systems into a formal organization that provides regular social services. Drawing on 7 months of ethnography and 36 formal interviews with staff and clients, I explore how transgender kinship organizations function, develop, and impact broader transgender community. Kinship organizations are highly responsive to crisis, are able to leverage personal and organizational resources, and are therefore capable of providing personalized rapid-response care to very precarious transgender people. On the other hand, subsuming kinship within a nonprofit transforms relationships of mutual care into unidirectional service relationships and relationships of chosen family into work-based hierarchies. This account of kinship organizations contributes to the theory on organizational development and provides new conceptual tools for analyzing boundaries between organizations and communities.

HIV Testing and Associated Characteristics Among Black Cisgender and Transgender Women in the United States

Black women in the United States continue to be disproportionately affected by HIV. HIV testing is an important preventative step in the HIV continuum of care, however there is little known about HIV testing among these groups. Therefore, the purpose of this study is to examine the HIV testing behaviors of Black transgender women and explore differences in predictors of HIV testing among Black cisgender and transgender women. This study uses secondary data from the 2014-2017 modules of the Behavioral Risk Factor Surveillance System. Analyses included multiple hierarchical regression. There are no major differences in HIV testing between Black cisgender and transgender women. A number of sociodemographic characteristics have been shown to predict HIV testing among Black cisgender women, but only employment status and age were significant predictors of HIV testing among Black transgender women. A moderation analysis suggested that gender identity significantly moderates the association between employment status and HIV testing such that the relationship between employment status and receiving an HIV test differs by gender identity. The findings of this study highlight nuances in HIV testing among Black cisgender and transgender women that are useful for improving HIV testing as a mode of HIV prevention. Overall, the findings contribute to our understanding of HIV testing practices among Black cisgender and transgender women.

Health and Health Care Access Barriers Among Transgender Women Engaged in Sex Work: A Synthesis of U.S.-Based Studies Published 2005-2019

Purpose: Transgender women (TW) are likely to experience job discrimination and engage in commercial sex transactions. As a group, they have the highest risk for HIV/AIDS. However, little is known about the health needs of transgender women sex workers (TWSW) in the United States and the structural and psychosocial barriers to their health care access. The objective of this systematic review was to systematically document these needs and barriers by using a framework approach. Methods: We searched PubMed, JSTOR, and Google Scholar for primary and secondary studies published in 2005-2019 that addressed the health of TWSW in the United States. We used a standardized data extraction form to gather data from eligible articles. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to assess study quality. Results: Fifty-three articles met the inclusion criteria, including mentioning health-related topics among TWSW. More articles appeared in recent years. Most studies collected data with convenience samples in urban areas. Structural barriers reported included transphobia, lack of pre-exposure prophylaxis targeted at TW, and lack of health insurance coverage. Psychosocial barriers included distrust of the health care system, self-esteem, alcohol and substance use, and mental health. Conclusions: TWSW have unique health care needs that are not being addressed due to barriers to health care access. More research is required to identify non-HIV-related health burdens and details about psychosocial barriers to health care access.

Narratives of transphobic violence in the Mexican province of Colima: A psychosocial analysis

BACKGROUND

Mexico has the second-highest index of crimes motivated by transphobia in the world. Transphobic violence manifests in a pervasive and complex manner in a country where violence permeates all aspects of social life. Some progress has been made to improve transgender rights and fight discrimination, but this has had an unequal impact in different geopolitical and cultural contexts within the country, particularly outside of metropolitan centers.

AIM

The study explores how transphobia is experienced in the conservative province of Colima and how transphobic practices play a part in shaping transgender subjective experience and identity construction. A psychosocial theoretical framework is adopted to attend to the relationship between cultural, institutional and interpersonal practices in this process.

METHODS

A qualitative approach is used to explore how different forms of transphobic violence are experienced by trans women in Colima. A purposive sample of 12 trans women, aged 22-38 years took part in narrative interviews which were analyzed thematically. Findings: The analysis is organized into three themes: (a) narratives of gender identity construction (b) gender expression and experiences of transphobic violence in Colima (c) sites for social support and change.

DISCUSSION

We argue that the psychosocial processes related to transphobia are context-specific shaping transgender identities and limiting and regulating gender expression. Family, education, LGBT community and the police were identified as key sites for support against or source of transphobic violence.

CONCLUSION

Despite the challenging socio-political context interventions are needed in policy and institutional practices to tackle stigma, transphobia and, trans-misogyny and improve the lives of transgender people living in regional areas in the global south.

"Multiplicity, Race, and Resilience: Transgender and Non-Binary People Building Community"

Scholars theorize that the development of community is an important part of resilience. In this mixed-methods study, we argue that race informs the experiences that transgender and non-binary (TNB) people have in seeking community. Using the Strengthening Colors of Pride Phase I and Phase II research, we argue that in a Latinomajority city, Latinx and Anglo TNB people connected with the transgender and broader lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, although Anglo TNB people reported more transphobia in the LGBTQ+ community. Black and American Indian TNB people connected with LGBTQ+ communities of color specifically and struggled more to find in-person community. Anglo TNB people used their own White racial networks to connect with supportive hobby and interest groups. In general, TNB people connected more with communities that resonated with the multiplicities of their own lives, such as commonalities of economic precarity and immigration status. This research is an important contribution to understanding the development of community for resilience, and the way race and gender identity inform community experiences for TNB people.

Effects of hormones and hormone therapy on breast tissue in transgender patients: a concise review

PURPOSE

Hormone replacement therapy (HRT) has become a mainstay medical treatment option for management of gender dysphoria in transgender patients of both biologic sexes. Very little is known about the long-term effects of steroid hormone modulation on breast tissue in this population. Most of the data available on the effects of HRT on breast and reproductive tissues come from studies of postmenopausal cisgender women. Therapeutic regimens are often provider-dependent, and there, are no uniform guidelines in place for cancer surveillance in transgender patients. In this review, we present what forms of hormone therapy and hormone modulation are available to transgender patients, what is known about their effects on male and female breast tissue, and what other endogenous and exogenous factors contribute to the macroscopic and cellular changes observed.

METHODS

A search for the existing literature focusing on therapeutic regimens and the effects of HRT on breast tissue provided the most current information available for this review. Recent evidence-based reports (since the year 2000) and reviews were given priority over anecdotal evidence and expert opinions when conflicting information was encountered. Older resources were considered when primary sources were needed. Given the paucity of available articles on this subject, all resources were given careful consideration.

RESULTS

Information about the risks associated with HRT in the current literature and in this setting is limited and often conflicting, due to a scarcity of long-term studies tracking breast pathology among transgender men and women.

CONCLUSIONS

We conclude that the long-term effects of off-label pharmaceutical use for modulation of hormone levels and sexual characteristics in transgender patients have not been well studied. The tendency of steroid hormones to promote the growth of certain cancers also raises questions about the safety of differing doses and drug combinations. Further clinical and laboratory study is needed to better establish safety and dosing guidelines in transgender patients.

The Transgender Identity Survey: A Measure of Internalized Transphobia

Purpose: We describe the development of a measure of internalized transphobia, defined as discomfort with one's transgender identity as a result of internalizing society's normative gender expectations. Methods: An item pool was created based on responses from a small clinical sample (N = 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18-72, mean [M] = 37.4, standard deviation [SD] = 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18-66, M = 31.6, SD = 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample. Results: EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test-retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity. Conclusion: Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people's health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.

Comparison of Two Distinct House Ball Communities Involved in an HIV Prevention Study: Baseline Data from the POSSE Project

For many Black/African American gay, bisexual, and other young men who have sex with men (B-GBMSM), the House/Ball Community (HBC) offers a social network where they can be free to express diverse sexual and gender identities, but HIV prevalence and stigma are high. The POSSE project is an effectiveness-implementation trial of a popular opinion leader intervention designed to address HIV prevention in the Chicago and Philadelphia HBCs. In June 2016 baseline behavioral data were collected along with HIV, gonorrhea and Chlamydia testing. Eligible participants were sexually-active YMSM or transgender women (TGW), between the ages of 15-24, who self-identified as Black. One-third participants (32.5%) met or exceeded the clinical cut-off for depressive symptoms. Approximately 18% of the participants across both cities reported that they were HIV-positive. Overall, the baseline data establishes the need for HIV and STI prevention interventions across both cities, as well as interventions to address other co-occurring epidemics.

American Cohort to Study HIV Acquisition Among Transgender Women in High-Risk Areas (The LITE Study): Protocol for a Multisite Prospective Cohort Study in the Eastern and Southern United States

BACKGROUND

In the United States, transgender women (TW) are disproportionately burdened by HIV infection. Cohort studies are needed to evaluate factors driving HIV acquisition among TW over time. These will require implementation strategies that are acceptable to the TW community and feasible to implement.

OBJECTIVE

This study aims to investigate the rate and correlates of HIV acquisition and other health outcomes among TW in eastern and southern United States.

METHODS

LITE is a multisite prospective cohort in 6 eastern and southern US cities, which will be followed across 24 months of technology-enhanced biobehavioral follow-up. Adult TW, regardless of HIV status, are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants are enrolled in a baseline study visit, complete a sociobehavioral survey, and test for HIV and sexually transmitted infections. Participants who are not living with HIV at baseline are offered enrollment into the cohort (N=1100); follow-up assessments occur quarterly.

RESULTS

Cohort assembly was informed by synchronous Web-based focus group discussions with TW (n=41) and by continuing engagement with community advisory board members from each site. Enrollment launched in March 2018. The study is underway in the Atlanta; Baltimore; Boston; Miami; New York City; and Washington, DC, metro areas. As of March 2019, 795 TW completed a baseline visit (mean age 35 years). The majority of the participants are racial/ethnic minorities, with 45% of the TW identifying as black and 28% of the TW identifying as Hispanic/Latinx. More than one-quarter (28%) of the TW are living with HIV infection (laboratory-confirmed). Online recruitment methods support engagement with TW, although peer referral and referral through trusted health facilities and organizations remain most effective.

CONCLUSIONS

This study is responsive to increasing research interest in technology-enhanced methods for cohort research, particularly for hard-to-reach populations. Importantly, the diversity of literacy, technology use, and overall socioeconomic situations in this sample of TW highlights the need to leverage technology to permit a flexible, adaptive methodology that enhances engagement of potential participants living in marginalized contexts while still ensuring rigorous and sound study design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14704.

Alternative kinship structures, resilience and social support among immigrant trans Latinas in the USA

Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population's high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.

Correlates of HIV infection among transgender women in two Chinese cities

Background

In an era when HIV transmission has been on the rise among men who have sex with men (MSM), transgender women may play a considerable role in China’s current HIV epidemic as a potential “bridge” of HIV transmission between homosexual and heterosexual populations. We sought to understand the risk behaviours and factors associated with HIV infection among transgender women in two cities in China.

Methods

From January to December 2016, we recruited transgender women with the help of community-based organizations (CBOs) through a wide range of methods, including snowball sampling. After recruitment, we asked participants to fill out a structured questionnaire including questions about socio-demographics, sexual behaviours, condom use, substance use and uptake of health care services. HIV infection status was determined by using two different rapid testing reagents.

Results

Among 498 subjects enrolled in this study, 233 were from Shanghai and 265 were from Tianjin. The median age was 30 years (range: 18–68; IQR: 24–33). Of them, 337 (67.7%) preferred feminine dress, 13 (2.6%) had undergone transsexual operation and 68 (13.7%) had used hormones for transition purposes. Nearly half (45.6%) reported having regular partners, and 351 (70.5%) had casual partners. Regarding condom use, 81.5% reported not always using condoms with stable partners, and 70.9% reported not using condoms with casual partners. Twenty-five (5.0%) had a history of buying sex and fifty-one (10.2%) had a history of selling sex in the past three months. A total of 200 (40.2%) participants had used at least one kind of controlled substance in the past six months. The most commonly used substances were amyl nitrates (rush popper) (99.5%) and 5-MeO-DiPT (20.0%). Among rush popper users, 170 (85.4%) reported always having sex while on the drug, and 177 (88.9%) reported increased sexual pleasure after using the drug. The HIV infection risk factors identified in our study were being located in Shanghai (aOR = 9.35, 95% CI = 3.89–22.49), selling sex in the past three months (aOR = 3.44, 95% CI = 1.31–9.01), and substance use in the past six months (aOR = 5.71, 95% CI = 2.63–12.41).

Conclusions

Transgender women bear a high HIV burden in the two Chinese cities. Those involved in commercial sex tended to have inconsistent condom use, leading to high risk of HIV infection. Substance use was an independent risk factor of HIV infection by increasing sexual activities and unprotected sex, which indicated an aggravated and complex situation with possible interacting syndemic factors that could cumulatively facilitate sexual risk behaviours and HIV infection in transgender women. There is an urgent need for innovative and appropriate HIV prevention programmes targeting this unique population. Efforts should be made to provide them with tailored services including persuasive communication on consistent condom use, substance use counselling and related referral services, all with the goal of reducing HIV epidemic among transgender women.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0508-2) contains supplementary material, which is available to authorized users.

Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998-1999 to 2015-2016

Data from two studies of transgender women in Los Angeles County that used the same methodology and survey assessment (Study 1: 1998-1999, N = 244; Study 2: 2015-2016, N = 271), compared structural determinants of health, HIV/STI prevalence, HIV risk behaviors, substance use, gender confirmation procedures, and perceived discrimination and harassment/abuse across a 17-year time period. Findings demonstrated that participants in the latter study reported significantly higher access to healthcare insurance and prescription hormones. However, participants in the latter study also reported lower levels of income; and, elevated prevalence of homelessness, HIV and lifetime STIs, receptive condomless anal intercourse with casual partner(s), and reported physical harassment/abuse. Given the timeframe of these results, these findings elucidate specific areas of transgender women's health and risk profiles that improved or worsened across 17 years. While healthcare access has improved, transgender women continue to face significant barriers to good health, indicating the need for increased attention to this population.

Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County

In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including "fillers"), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women.

THE IMPACT OF CONSTRUCTION AND GENTRIFICATION ON AN OUTDOOR TRANS SEX WORK ENVIRONMENT: VIOLENCE, DISPLACEMENT AND POLICING

The objective of this study was to investigate how environmental and structural changes to a trans outdoor work environment impacted sex workers in Vancouver, Canada. The issue of changes to the work area arose during qualitative interviews with 33 trans sex workers. In response, ethnographic walks that incorporated photography were undertaken with trans sex workers. Changes to the work environment were found to increase vulnerabilities to client violence, displace trans sex workers, and affect policing practices. Within a criminalized context, construction and gentrification enhanced vulnerabilities to violence and harassment from police and residents.

Victimization and Human Immunodeficiency Virus-Related Risk Among Transgender Women in India: A Latent Profile Analysis

Globally, transgender women (TGW) experience multiple forms of victimization such as violence and discrimination that can place them at risk for poor sexual health. To date, research overlooks the heterogeneity in experiences of victimization among TGW. Furthermore, few studies have examined the association between victimization and sexual risk among TGW in India, despite the high burden of HIV and victimization in this community. Latent profile analysis was performed to identify patterns of victimization in a convenience sample of 299 TGW recruited from nongovernmental organizations across four states in India. Analysis of covariance was performed to examine differences in sexual risk (i.e., alcohol use before sex; inconsistent condom use with a male regular partner, a male causal partner, and a male paying partner; and having multiple sexual partners) between latent profiles. Five distinct profiles of Indian TGW were identified based on the type and severity of victimization: (1) Low victimization, (2) High verbal police victimization, (3) High verbal and physical police victimization, (4) Moderate victimization, and (5) High victimization. While controlling for age, education, income, HIV status, and marital status, results revealed that TGW in the moderate victimization and high victimization profiles had higher sexual risk than TGW in the low victimization and high verbal police victimization profiles. In addition, TGW in high verbal and physical police victimization profile had higher sexual risk than TGW in low victimization profile. These findings underscore the importance of tailoring sexual risk reduction interventions to the specific needs of TGW based on patterns of victimization.

HIV Prevention in Gay Family and House Networks: Fostering Self-Determination and Sexual Safety

Many gay, bisexual, and transgender (GBT) people of color (POC) join house and/or constructed family communities, which serve as support networks composed mostly of other non-biologically related GBT/POC. These networks can decrease or increase the risk of exposure to HIV via multiple mechanisms (e.g., providing informal sexual safety education versus stigmatizing family members with HIV, encouraging sexual safety practices versus unsafe escorting, teaching self-care versus substance use) but act to support family members in the face of social and economic hardship. Researchers interviewed ten members of these social networks in the Boston metro area of the US and produced a saturated grounded theory analysis to explore the role of gay family/house networks in HIV risk management. While network members utilized HIV prevention resources, interviewees described how their efficacy was related to the intentions of leadership and strength of kinship boundaries within their community, economic opportunities, and communication skills. Clinical and research implications are discussed.

Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru

Introduction: In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community-level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.

Methods: Using qualitative methodology to provide an in-depth portrait, we assessed (1) intersections between social marginalization, social capital and HIV vulnerabilities; and (2) community-level resilience strategies employed by TW to buffer against social marginalization and to link to needed HIV-related services in Peru. Between January and February 2015, 48 TW participated (mean age = 29, range = 18–44) in this study that included focus group discussions and demographic surveys. Analyses were guided by an immersion crystallization approach and all coding was conducted using Dedoose Version 6.1.18.

Results: Themes associated with HIV vulnerability included experiences of multilevel stigma and limited occupational opportunities that placed TW at risk for, and limited their engagement with, existing HIV services. Emergent resiliency-based strategies included peer-to-peer and intergenerational knowledge sharing, supportive clinical services (e.g. group-based clinic attendance) and emotional support through social cohesion (i.e. feeling part of a community).

Conclusion: This study highlights the importance of TW communities as support structures that create and deploy social resiliency-based strategies aimed at deterring and mitigating the impact of social vulnerabilities to discrimination, marginalization and HIV risk for individual TW in Peru. Public health strategies seeking to provide HIV prevention, treatment and care for this population will benefit from recognizing existing social capital within TW communities and incorporating its strengths within HIV prevention interventions. At the intersection of HIV vulnerabilities and collective agency, dimensions of bridging and bonding social capital emerged as resiliency strategies used by TW to access needed healthcare services in Peru. Fostering TW solidarity and peer support are key components to ensure acceptability and sustainability of HIV prevention and promotion efforts.

Health Care Use and HIV-Related Behaviors of Black and Latina Transgender Women in 3 US Metropolitan Areas: Results From the Transgender HIV Behavioral Survey

PURPOSE

HIV prevalence estimates among transgender women in the United States are high, particularly among racial/ethnic minorities. Despite increased HIV risk and evidence of racial disparities in HIV prevalence among transgender women, few data are available to inform HIV prevention efforts.

METHODS

A transgender HIV-related behavioral survey conducted in 2009 in 3 US metropolitan areas (Chicago, Houston, and Los Angeles County), used respondent-driven sampling to recruit 227 black (n = 139) and Latina (n = 88) transgender women. We present descriptive statistics on sociodemographic, health care, and HIV-risk behaviors.

RESULTS

Of 227 transgender women enrolled, most were economically and socially disadvantaged: 73% had an annual income of less than $15,000; 62% lacked health insurance; 61% were unemployed; and 46% reported being homeless in the past 12 months. Most (80%) had visited a health care provider and over half (58%) had tested for HIV in the past 12 months. Twenty-nine percent of those who reported having an HIV test in the past 24 months self-reported being HIV positive. Most of the sample reported hormone use (67%) in the past 12 months and most hormone use was under clinical supervision (70%). Forty-nine percent reported condomless anal sex in the past 12 months and 16% reported ever injecting drugs.

CONCLUSION

These findings reveal the socioeconomic challenges and behavioral risks often associated with high HIV risk reported by black and Latina transgender women. Despite low health insurance coverage, the results suggest opportunities to engage transgender women in HIV prevention and care given their high reported frequency of accessing health care providers.

Gender Differences in HIV Care among Criminal Justice-Involved Persons: Baseline Data from the CARE+ Corrections Study

Background

HIV-infected individuals recently released from incarceration have suboptimal linkage and engagement in community HIV care. We conducted a study to evaluate an information and communication technology intervention to increase linkage to community care among HIV-infected persons recently involved in the criminal justice (CJ) system. Baseline characteristics including risk behaviors and HIV care indicators are reported and stratified by gender.

Methods

We recruited HIV-infected individuals in the District of Columbia jail and persons with a recent history of incarceration through community and street outreach. Participants completed a baseline computer-assisted personal interview regarding HIV care and antiretroviral treatment (ART) adherence, substance use, and sexual behaviors. CD4 and HIV plasma viral load testing were performed at baseline or obtained through medical records. Data were analyzed for the sample overall and stratified by gender.

Results

Of 110 individuals, 70% were community-enrolled, mean age was 40 (SD = 10.5), 85% were Black, and 58% were male, 24% female, and 18% transgender women. Nearly half (47%) had condomless sex in the three months prior to incarceration. Although drug dependence and hazardous alcohol use were highly prevalent overall, transgender women were more likely to have participated in drug treatment than men and women (90%, 61%, and 50% respectively; p = 0.01). Prior to their most recent incarceration, 80% had an HIV provider and 91% had ever taken ART. Among those, only 51% reported ≥90% ART adherence. Fewer women (67%) had received HIV medications during their last incarceration compared to men (96%) and transgender women (95%; p = 0.001). Although neither was statistically significant, transgender women and men had higher proportions of baseline HIV viral suppression compared to women (80%, 69%, and 48.0% respectively, p>0.05); a higher proportion of women had a CD4 count ≤200 compared to men and transgender women (17%, 8% and 5% respectively; p>0.05).

Conclusions

In this study, HIV-infected persons with recent incarceration in Washington, DC reported important risk factors and co-morbidities, yet the majority had access to HIV care and ART prior to, during, and after incarceration. Self-reported ART adherence was sub-optimal, and while there were not statistically significant differences, CJ-involved women appeared to be at greatest risk of poor HIV outcomes.

Trial registration

Registered on ClinicalTrials.gov on 10/16/2012. Reference number: NCT01721226.

HIV Knowledge, Risk Behavior, Stigma, and Their Impact on HIV Testing among Asian American and Pacific Islanders: A Review of Literature

Asian American and Pacific Islanders (AAPIs) are the fastest growing population in the United States with documented increases in HIV rates. AAPIs are as likely as other racial/ethnic groups to engage in HIV-related risk behaviors, while being concomitantly less likely to have been HIV tested. Testing is a critical step in HIV prevention. Research points to various barriers to HIV-related testing including HIV knowledge and attitude and stigma. However, these factors and their impact among AAPIs are poorly understood. Myths about this population's "model minority" status compound AAPIs' sociocultural factors including English language proficiency, access to healthcare, and a culture of "silence" that negatively influences HIV-related research. In this article, the authors review the scientific literature on knowledge, risk behavior, and stigma to document the current state of research. Based on the review the authors offer a set of research, policy, and practice recommendations for social workers and other service providers working with AAPIs.

Autogynephilia and the Typology of Male-to-Female Transsexualism

Abstract. Sexual scientists have recognized for over a century that biologic males who seek sex reassignment – male-to-female (MtF) transsexuals – are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard’s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care.

Negotiating Violence in the Context of Transphobia and Criminalization: The Experiences of Trans Sex Workers in Vancouver, Canada

A growing body of international evidence suggests that sex workers face a disproportionate burden of violence, with significant variations across social, cultural, and economic contexts. Research on trans sex workers has documented high incidents of violence; however, investigations into the relationships between violence and social-structural contexts are limited. Therefore, the objective of this study was to qualitatively examine how social-structural contexts shape trans sex workers' experiences of violence. In-depth semistructured interviews were conducted with 33 trans sex workers in Vancouver, Canada, between June 2012 and May 2013. Three themes emerged that illustrated how social-structural contexts of transphobia and criminalization shaped violent experiences: (a) transphobic violence, (b) clients' discovery of participants' gender identity, and (c) negative police responses to experiences of violence. The findings demonstrate the need for shifts in sex work laws and culturally relevant antistigma programs and policies to address transphobia.

Major Contribution Reaction

The author of this invited reaction comments on the four articles within the Major Contribution titled “Research on Trans People and Issues.” The Major Contribution authors have successfully met the three goals they set for this work: to (a) review the current state of psychosocial trans scholarship and identify next directions, (b) propose a critical research approach to decision making in trans study activities, and (c) exemplify how this critical research approach may be applied within an empirical study with trans participants. The Major Contribution is a next step in the long history of advocacy for trans researchers to be more attentive to centering the voices of trans people. In this reaction, I enthusiastically support the spirit of the Major Contribution, provide feedback on the articles, and encourage the trans research field to implement the authors’ recommendations and continue to look for ways to reach further toward supporting trans liberation.

Trans Women Doing Sex in San Francisco

This research investigates the sexuality of trans women (individuals who were assigned male status at birth who currently identify as women), by focusing on the "bodily techniques" (Crossley, 2006) they use in "doing" sexuality. The "doing sexuality" framework not only is modeled after the "doing gender" approach of West and Zimmerman (1987), but also utilizes the idea of "sexual embodiment" to emphasize the agency of trans women as they conceptualize and organize their sexuality in a socially recognized way. This is often difficult as they confront discrimination from medical and legal professionals as well as intimate partners who may find it difficult to adapt to the trans woman's atypical body and conception of gender. However, with a study group of 25 trans women from San Francisco, we found the study participants to be adept at overcoming such hurdles and developing techniques to "do" their sexuality. At the same time, we found trans women's agency constrained by the erotic habitus (Green, 2008) of the wider society. The interplay between innovation and cultural tradition provides an opportunity to fashion a more general model of "doing" sexuality.

Sociodemographic Characteristics and Psychological Adjustment Among Transsexuals in Spain

This study examined the sociodemographic characteristics and the psychological adjustment of transsexuals in Andalusia (Spain), and also analyzed the differences between female-to-male (FtM) and male-to-female (MtF) transsexuals. The sample included 197 transsexuals (101 MtF and 96 FtM) selected from those who visited the Transsexual and Gender Identity Unit at the Carlos Haya Hospital in Malaga between 2011 and 2012. Our analyses indicated that MtF transsexuals were more likely to have lower educational levels, live alone, have worked less frequently throughout their lifetime, and have engaged in prostitution. For FtM transsexuals, there were more frequent references to the mother's psychiatric history and more social avoidance and distress. Multivariate analysis showed that the number of personality dysfunctional traits and unemployment status were associated with depression in the entire sample. The following three conclusions can be made: there are significant differences between MtF and FtM transsexuals (mainly related to sociodemographic variables), depression was high in both groups, and a remarkable percentage of transsexuals have attempted suicide (22.8 %) or have had suicidal thoughts (52.3 %).

Gender Abuse and Incident HIV/STI Among Transgender Women in New York City: Buffering Effect of Involvement in a Transgender Community

In a 3 year prospective study of 230 transgender women from the New York City Area, we further examined associations of gender-related abuse with HIV sexual risk behavior and incident HIV/STI, focusing here and the extent to which these associations are buffered by involvement in a transgender community. Largely consistent with the prior study, gender abuse was longitudinally associated with unprotected receptive anal intercourse (URAI) with casual and commercial sex partners, and the presumed biological outcome of this behavioral risk, new cases of HIV/STI. Both of these associations, gender abuse with URAI and HIV/STI, were significantly buffered by transgender community involvement (interaction effects). However, independent of these interaction effects, transgender community involvement was also positively associated with URAI and HIV/STI (direct effects). HIV prevention in this population should emphasize the benefits of interactions with transgender peers while also emphasizing the importance of resisting normative permission for HIV risk behavior from these same peers.

Differential HIV risk for racial/ethnic minority trans*female youths and socioeconomic disparities in housing, residential stability, and education

OBJECTIVES

We examined HIV prevalence and risk behaviors of 282 trans*female youths aged 16 to 24 years participating in the San Francisco Bay Area, California, SHINE study from 2012 to 2013 to determine differences between racial/ethnic minority and White youths.

METHODS

We conducted the χ(2) test to determine distributional differences between racial/ethnic minority and White participants in sociodemographic factors, HIV-related risk behaviors, and syndemic factors.

RESULTS

Of the trans*female youths, 4.8% were HIV positive. Racial/ethnic minority and White trans*female youths differed significantly in gender identity and sexual orientation. Racial/ethnic minority youths also had significantly lower educational attainment, were less likely to have lived with their parents of origin as a child, and were significantly more likely to engage in recent condomless anal intercourse than were Whites.

CONCLUSIONS

Efforts to assess the impact of multiple-minority stress on racial/minority trans*female youths are needed imminently, and prevention efforts must address macrolevel disparities for trans*female youths, especially those from racial/ethnic minority groups, to reduce these disparities and prevent incident cases of HIV.

HIV risk and preventive interventions in transgender women sex workers

Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.

HIV risk and preventive interventions in transgender women sex workers

Worldwide, transgender women who engage in sex work have a disproportionate risk for HIV compared with natal male and female sex workers. We reviewed recent epidemiological research on HIV in transgender women and show that transgender women sex workers (TSW) face unique structural, interpersonal, and individual vulnerabilities that contribute to risk for HIV. Only six studies of evidence-based prevention interventions were identified, none of which focused exclusively on TSW. We developed a deterministic model based on findings related to HIV risks and interventions. The model examines HIV prevention approaches in TSW in two settings (Lima, Peru and San Francisco, CA, USA) to identify which interventions would probably achieve the UN goal of 50% reduction in HIV incidence in 10 years. A combination of interventions that achieves small changes in behaviour and low coverage of biomedical interventions was promising in both settings, suggesting that the expansion of prevention services in TSW would be highly effective. However, this expansion needs appropriate sustainable interventions to tackle the upstream drivers of HIV risk and successfully reach this population. Case studies of six countries show context-specific issues that should inform development and implementation of key interventions across heterogeneous settings. We summarise the evidence and knowledge gaps that affect the HIV epidemic in TSW, and propose a research agenda to improve HIV services and policies for this population.

Housing status and HIV risk behaviors among transgender women in Los Angeles

Due to social stigma, lack of social support, and minimal legal employment opportunities, transgender women (transwomen) face elevated rates of unstable housing. This study examined the association between housing status and HIV risk behaviors among 517 transwomen encountered through street outreach. Seven variables (including sociodemographics, HIV status, housing status, and sexual partner type) were used to estimate partial associations during multivariable analyses; housing status was coded trichotomously (housed, marginally housed, and homeless) for these analyses. Results demonstrated that homeless and marginally housed transwomen engaged in significantly higher rates of illicit drug use than housed transwomen; however, marginally housed and housed transwomen engaged in significantly higher rates of illegal hormone injections than homeless transwomen. Rates of sex work were high in the sample as a whole, though sex with an exchange partner was most common among the marginally housed transwomen. Multivariate logistic regression revealed that unstable housing moderated the association between HIV status and engagement in unprotected serodiscordant anal intercourse. The marginally housed transwomen exhibited the greatest risk profile for HIV acquisition or transmission.

African American Gay Family Networks: An Entry Point for HIV Prevention

Gay families are constructed support networks that gay, bisexual, and transgender individuals of color form, often in response to societal marginalization and rejection from biological families. Research on these family structures has been scarce, with little focus on the experience of African American gay family networks in the South. The current grounded theory qualitative study focused on the experiences of 10 African American male and transgender individuals between the ages of 18 and 29 from gay families in the Mid-South, and explored the ways these families addressed safe-sex issues and human immunodeficiency virus (HIV) risk prevention. Results revealed that families can play a role in either increasing HIV risk (e.g., ignoring HIV issues, encouraging such unsafe behaviors as exchanging sex for money or drugs, stigmatizing HIV-positive people) or decreasing it (e.g., intensive, family-level prevention efforts at safe-sex practices and family support for HIV treatment adherence). The potential of these family networks for HIV prevention and adherence efforts is considered.

HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach

Transgender women ("transwomen") face a disproportionate HIV disease burden; the odds of being HIV-positive are estimated to be 34.2 times higher for transwomen than the United States adult population. From January 1, 2005 through December 31, 2011, HIV prevention outreach encounters were conducted with 2,136 unique transwomen on the streets and at high-risk venues in Los Angeles County. The outreach encounters were comprised of a low-intensity health education and risk reduction intervention, which included referrals to needed services. The goal of the encounters was to assess the participant's level of substance use and sexual risk behaviors to provide appropriate risk reduction strategies and supplies. The sample evidenced high rates of recent alcohol (57.7 %), marijuana (25.6 %), and methamphetamine (21.5 %) use, lifetime injection drug or illegal hormone use (66.3 %), and recent engagement in sex work (73.3 %). Multivariate logistic regression analysis revealed that recent methamphetamine (AOR = 2.09; p ≤ 0.001) and/or crack cocaine (AOR = 2.19; p = 0.010) use, injection drug/hormone use (AOR = 1.65; p ≤ 0.001), unprotected anal intercourse during sex work (AOR = 2.24; p = 0.029), and any non-Hispanic minority racial status were all associated with increased odds of reporting a HIV-positive status. The transwomen encountered via outreach exhibited many risk co-factors for HIV infection and transmission.

HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample

To study the influence of gender on HIV risk, a sample of the U.S. transgender population (N = 1,229) was recruited via the Internet. HIV risk and prevalence were lower than reported in prior studies of localized, urban samples but higher than the overall U.S. population. Findings suggest that gender nonconformity alone does not itself result in markedly higher HIV risk. Sex with nontransgender men emerged as the strongest independent predictor of unsafe sex for both male-to-female (MtF) and female-to-male (FtM) participants. These sexual relationships constitute a process that may either affirm or problematize gender identity and sexual orientation, with different emphases for MtFs and FtMs, respectively.

Adolescent gender-related abuse, androphilia, and HIV risk among transfeminine people of color in New York City

Public health research has indicated extremely high HIV seroprevalence (13%-63%) among low-income transfeminine people of color of African, Latina, and Asian descent living in the U.S. This article combines two data sets. One set is based on an ethnographic study (N = 50, 120 hours of participant observation). The other set is based on a longitudinal quantitative study (baseline N = 600, N = 275 followed for 3 years). Transfeminine people of color are much more likely to be androphilic and at high HIV risk. A greater understanding of adolescent gender-related abuse and trauma-impacted androphilia contributes toward a holistic conceptual model of HIV risk. A theoretical model is proposed that incorporates findings from both studies and integrates sociostructural, interpersonal, and intrapsychic levels of HIV risk.

A critical analysis of Peru's HIV grant proposals to the Global Fund

Peru has applied to six of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) rounds for funding, achieving success on four occasions. The process of proposal development has, however, been criticised, especially concerning the use of evidence, relevance/consistency and performance indicators. We aimed to analyse the Peruvian Global Fund proposals according to those dimensions, providing feedback to improve future local efforts and inform global discussions around Global Fund procedures. We analysed the content of four HIV-focused proposals (rounds 2, 5, 6 and 8) regarding epidemic context, needs identification and prioritisation and monitoring and evaluation systems. Peruvian proposals submitted after round 1 were described as resulting from collaborative inputs involving formerly unrepresented sectors, principally 'vulnerable populations'. However, difficulties arose regarding the amount and quality of evidence about the epidemiological context; limited consideration of social determinants of the epidemic; lack of theory-driven interventions, and little synergy across projects and the inclusion of weak monitoring and evaluation systems, with poor indicators and measurement procedures. Prioritising the development of analytical and technical skills to generate Global Fund proposals would enhance the country's capacity to produce and utilise evidence, improve the technical-political interface, strengthen information systems and lead to more informed decision making and accountability.

Client demands for unsafe sex: the socioeconomic risk environment for HIV among street and off-street sex workers

OBJECTIVE

Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients' demand for sex without a condom.

DESIGN

Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs.

METHODS

A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money.

RESULTS

The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places).

CONCLUSIONS

These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

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

BACKGROUND

There is a dearth of health research about transgender people.

OBJECTIVES

This mixed-methods study sought to formatively investigate the health and perceived health needs of female-to-male transmasculine adults.

DESIGN

A cross-sectional quantitative needs assessment (n = 73) and qualitative open-ended input (n = 19) were conducted in June 2011. A latent class analysis modeled six binary health indicators (depression, alcohol use, current smoking, asthma, physical inactivity, overweight status) to identify clusters of presenting health issues.

RESULTS

Four clusters of health indicators emerged: (a) depression; (b) syndemic (all indicators); (c) alcohol use, overweight status; and (d) smoking, physical inactivity, overweight status. Transphobic discrimination in health care and avoiding care were each associated with membership in the syndemic class. Qualitative themes included personal health care needs, community needs, and resilience and protective factors.

CONCLUSIONS

Findings fill an important gap about the health of transmasculine communities, including the need for public health efforts that holistically address concomitant health concerns.

Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey

Travestis are highly vulnerable to HIV infection in Brazil. We conducted a survey among 304 travestis using Respondent-Driven Sampling from August to December 2008. Travestis are young (49% <24 years), poorly educated (55% just elementary school), low social class (62% Class C-E), reside with families (49%) or friends/madam (22%), are victims of homophobia (91%) and violence (61%). They report early sexual debut (75% <14), many sexual partners, drug use during sex (43%), and unprotected sex (male partner, 47%, both male and female partners, 50%). Sex work is common (82%, 59% >10 partners last six months) and relatively low cost (median=US$24). A majority report testing for HIV (69%), and report high prevalence (12% disclosed a positive result). Almost all the respondents refused to test in the study. Interventions, targeted to both travestis and to the general community about sexual discrimination, are necessary.

Exploring the diversity of gender and sexual orientation identities in an online sample of transgender individuals

Although the term transgender is increasingly used to refer to those whose gender identity or expression diverges from culturally defined categories of sex and gender, less is known about the self-identities of those who fall within this category. Historically, recruitment of transgender populations has also been limited to specialized clinics and support groups. This study was conducted online, with the aim of exploring the gender identities, sexual orientation identities, and surgery and hormonal statuses of those who identify with a gender identity other than, or in addition to, that associated with their birth sex (n = 292). Genderqueer was the most commonly endorsed gender identity, and pansexual and queer were the most commonly endorsed sexual orientation identities. Participants indentified with a mean of 2.5 current gender identities, 1.4 past gender identities, and 2 past sexual orientation identities. The majority of participants either did not desire or were unsure of their desire to take hormones or undergo sexual reassignment surgery. However, birth sex and age were significant predictors of "bottom" surgery and hormone status/desire, along with several identities and orientations. This study explores explanations and implications for these patterns of identification, along with the potential distinctiveness of this sample.

Predictors of HIV Sexual Risk Behavior among Men Who Have Sex with Men, Men Who Have Sex with Men and Women, and Transgender Women

Men who have sex with men, men who have sex with men and women, and transgender women are at high risk for HIV infection. This study seeks to clarify which known HIV risk factors (partner type, sex location, serodiscordance, multiple sex partners, substance use during sex) contribute to engagement in high-risk (unprotected receptive anal) sex in each population. Data collected from June 2005 through June 2008 indicate all three populations display different HIV sexual risk profiles. The data suggest that HIV-prevention interventions should be individually tailored to address the specific needs of these three highly vulnerable and impacted populations.

Community-engaged research to identify house parent perspectives on support and risk within the House and Ball scene

This article describes a community-engaged study with the Los Angeles House and Ball scene in which the perspectives of the leaders of these communities are captured to better understand how the House and Ball communities may protect or increase its members' risks for HIV infection. Data were collected through in-depth interviews with House parents (N = 26). This study identified key features of both support (e.g., family and support, acceptance, and validation and recognition) and risk (e.g., members' struggles to maintain status in the Ballroom scene, sex work, substance use, danger of becoming too involved in the Ball community, and perception and stigma of the Ballroom scene within the larger gay community) within these communities. Findings are discussed in relation to framing how to leverage the supportive aspects of the House and Ball communities to design relevant HIV-prevention interventions.