Impact of minority stress in depressive symptoms, suicide idea and try suicide in trans

Social and programmatic vulnerability in the context of transgender people's health: a scoping review of scientific evidence from Brazil

BACKGROUND

Most transgender people face different conditions of health vulnerability on a daily basis. In the Brazilian context, no research review has been found on such situations in the light of the theoretical conceptualization of multidimensional vulnerability. This research aimed to identify and analyze components of social and/or programmatic vulnerability that interfere with access to health care for trans people in Brazil.

METHODS

The scoping review followed the JBI Manual and the PRISMA-ScR list. Brazilian studies published in any language, in the period 2019-April 2023, in the NCBI/PubMed, Web of Science, EMBASE, Scopus, SciELO, and LILACS databases were selected. The inclusion criteria included: original research with a sample of transgender people aged 18 years and over; and research contemplating conditions of social and/or programmatic vulnerability. Three reviewers independently selected the articles. The extracted and mapped data included components of these dimensions, according to the theoretical framework, as well as characteristics of the studies, for the synthesis of the descriptive analysis.

RESULTS

A total of 46 studies were included. Social and programmatic vulnerability components were present in 67% of the studies. Among the main findings, the social dimension included discrimination, situations of violence in different contexts and social exclusion; prejudice and school dropout, homelessness, informal work and precarious income; and harmful use of alcohol and/or other drugs. The programmatic dimension encompassed disrespect for the use of the social name and institutional discrimination; hormone therapy without professional monitoring and scarcity of specialized services; lack of integration between Primary Health Care (PHC) and specialized care and insufficient PHC involvement; distortions between what is contained in public health policies and the practice in the services. A higher percentage (61%) of studies with trans women and 7% with trans men were observed; inequalities in regional distribution; predominance of HIV and AIDS and mental health themes; and similar percentages in the various methodological approaches and publications in national and foreign journals.

CONCLUSION

The identified situations of vulnerability contribute mainly to supporting the formulation and implementation of new public policies in comprehensive health that are more comprehensive and inclusive, which mitigate the current social and health inequities.

Temporal trend and characteristics of notifications of self-inflicted and interpersonal violence in the transgender population in Brazilian municipalities, 2015-2022

OBJECTIVE

To analyze the temporal trend and characteristics of notifications of violence among the transgender population from 2015 to 2022 in Brazilian municipalities.

METHODS

This was a repeated panel epidemiological study, based on violence incidents reported among the transgender population aged 20 to 59 years, available in the Notifiable Health Conditions Information System. An annual temporal trend analysis was performed by means of generalized linear regression, using the Prais-Winsten method and spatial distribution of notifying municipalities in Brazil.

RESULTS

Notifications of violence in the transgender population decreased during the period (1.7%; β = -0.07; p = 0.010), but there was an increase in the number of notifying municipalities (45.8%), self-inflicted violence (28.9%; β = 2.21; p < 0.001) and sexual violence (β = 0.79; p < 0.001). The majority of perpetrators were male and in an affective relationship, especially with transgender women (43.4%; p < 0.001).

CONCLUSION

Notification of violence does not yet fully reflect the reality of this population, but it represents the first step towards visibility and addressing the issue.

MAIN RESULTS

Notifications of violence against transgender people accounted for 1.7% of the total. Self-inflicted and sexual violence increased from 2015 to 2022. Almost half of Brazilian municipalities have already been reporting cases of violence against this population.

IMPLICATIONS FOR SERVICES

Continuous and high-quality notification will contribute to monitoring and understand violence in this population group, enabling the adaptation of services to meet their specific needs.

PERSPECTIVES

The development of research on the transgender population will allow for a better understand and guidance of specific health actions for this group. Information on violence against this population is crucial for informing public policies.

The use of psychiatric medications and associated factors among people receiving care at a transgender outpatient clinic in Southern Brazil, 2021-2022

OBJECTIVE

To investigate the prevalence of psychiatric medication use and sociodemographic factors, including gender identity, age, race/skin color, education level, formal employment, and access to Primary Health Care (PHC) centers, among individuals receiving care at a transgender outpatient clinic in Southern Brazil.

METHODS

: This was a cross-sectional study using administrative data from the information systems of the Municipal Health Department of Porto Alegre, the capital city of Rio Grande do Sul state, collected between 2021 and 2022.

RESULTS

: This study analyzed 629 records of individuals who accessed the outpatient clinic and found a 29% prevalence (95%CI 25;32) of psychiatric medication use, with the most frequent class being psychoanaleptics (45%), especially fluoxetine (31%).

CONCLUSION

In addition to a trend toward mixed-race race/skin color and incomplete elementary school, transgender people aged 40 to 49 years and with access to a Primary Health Care center were more likely to use psychiatric medications.

MAIN RESULTS

Prevalence of 29% (95%CI 25;32) of psychiatric medication use was observed, with a higher likelihood among individuals aged 40 to 49 years, with access to primary healthcare centers. Low education level and mixed-race/skin color showed significant effect sizes. The most frequently dispensed drug class was psychoanaleptics (45%), with fluoxetine (31%) standing out.

IMPLICATIONS FOR SERVICES

This study can be replicated in other transgender outpatient clinics across Brazil and should contribute to broadening the discussion on mental healthcare for the transgender population.

PERSPECTIVES

The findings highlight the importance of interdisciplinary approaches to healthcare and underscore the need to assess the effectiveness of public mental health policies for the transgender population.

A mixed methods study of suicide protective factors in college students

INTRODUCTION

Mental health professionals, teachers, families, and public administrators are concerned about suicide rates among young people, particularly in the university context. For every ten college students worldwide, three attempt suicide in their lifetime, and two experience suicidal ideation. Reducing these rates requires interventions that recognize the problem in terms of risk factors and protective factors.

OBJECTIVE

The general aim of the study was to map the protective factors for suicide among college students, as perceived by them, mental health professionals, and coordinators of undergraduate courses in a public university in the North of Brazil.

METHODS

The study followed an exploratory, mixed-method design. Data were collected through interviews and the application of a questionnaire with 54 participants, including college students (n = 20), mental health professionals (n = 22), and course coordinators (n = 12). Data were analyzed using Content Analysis and simple descriptive statistics.

RESULTS

The findings show that the protective factors for suicide most cited among the three groups were social support, strengthening of internal resources, institutional support, and finding meaning about the change to enter the university. Although the three audiences did not converge, the protective factors also frequently reported were psychological treatment, leisure activities, religious engagement, medical treatment, civic engagement, employability, opportunities for social ascension offered by the university, and quality family relationships.

CONCLUSION

It is suggested that these protective factors are considered when formulating policies to promote mental health and suicide prevention in the university environment.

Factor structure and measurement invariance of the Body Appreciation Scale - 2 among Brazilian gender-expansive individuals and transgender men

Among gender-expansive individuals and transgender men, body appreciation can play a protective role against minority stressors and is associated with gender euphoria. The Body Appreciation Scale (BAS-2; Tylka & Wood-Barcalow, 2015) is a leading measure of body appreciation that has been mainly validated in cisgender and mixed-gender samples; however, it has not been validated among Brazilian gender-expansive individuals and transgender men. Therefore, we evaluated the psychometric properties of the BAS-2 among adult Brazilian gender-expansive individuals and transgender men. Participants (158 gender-expansive individuals and 138 transgender men) were recruited through social media in Brazil. Confirmatory Factor Analysis (CFA) supported the original 10-item, unidimensional solution. Multigroup CFA showed configural, metric, and scalar invariance of the BAS-2 between gender-expansive individuals and transgender men. Moreover, the BAS-2 demonstrated significant negative associations, ranging from small to large, with self-objectification, drive for muscularity, and appearance-ideal internalization. We also found good internal consistency and test-retest reliability of the measure. Taken together, our results support the psychometric properties of the BAS-2 among Brazilian gender-expansive individuals and transgender men. The present work offers a valuable contribution towards better understanding facets of positive body image across gender-expansive and transgender populations.

Difficulties and advances in access to and use of health services by transgender women and travestis in Brazil

OBJECTIVE

To understand the narratives of transgender women and travestis (TGW) from four Brazilian cities regarding access to and use of health services.

METHODS

Qualitative study carried out within the scope of the TransOdara project, cross-sectional multicenter mixed methods research conducted between 2019-2021. Fifty-two in-depth interviews with TGW in Manaus, Campo Grande, Porto Alegre and São Paulo were analyzed. The analysis was guided by philosophical hermeneutics.

RESULTS

Reports of discrimination, stigmatization and pathologization reiterate the difficulties faced by TGW in seeking healthcare. The recurrence of disrespect for the social/corrected name reveals obstacles to the recognition of transgender identities and, in some cases, the intention of inhibiting transsexuality-travestilidade. Other difficulties arise from actions that disregard the health specificities of TGW or the precarious social conditions that affect some of them. On the other hand, based on experiences of respect and adequate care, participants identify an ongoing change, which is expressed in greater availability of services and improved assistance. There is an expectation of continued expansion of services, technologies and training of health professionals.

CONCLUSIONS

The identified change has been undertaken at the interface of public health policies with LGBT+ activism and the production of knowledge about TGW health needs. Although the identified advances are insufficient to change the scenario of the historical exclusion experienced by TGW in health services, they point to promising ways to improve their health conditions.

Medical care for transgender individuals at a hospital in southern Brazil: why do they drop out from our service?

Objective

The objective of the study was to investigate dropout rates and discern potential factors contributing to the discontinuation of treatment provided to transgender individuals by the Transdisciplinary Gender Identity Program at the Hospital de Clínicas de Porto Alegre (PROTIG).

Methodology

This study employs a descriptive, cross-sectional, retrospective design to analyze socio-demographic and clinical data obtained from medical records of patients treated at PROTIG between 2000 and 2018. A structured form, devised by PROTIG's professional team, was utilized to extract and evaluate several variables including: age, gender, education level, diagnosis of F64 according to the International Classification of Diseases (ICD-10: Version: 2010), clinical comorbidities (coded by ICD-10), laboratory diagnosis of sexually transmitted infections, distance between patients' residence and the hospital, and year of entry into PROTIG. The patient cohort was stratified into two categories based on their duration of attendance: dropout (defined as attendance for up to 365 days) and non-dropout (attendance exceeding 365 days). Categorical variables between dropout and non-dropout groups were compared using Pearson's chi-square test. Additionally, Poisson regression analysis was utilized, employing a 95% confidence interval (CI) and setting the significance level at 0.05.

Results

The study included a total of 888 patients accessing PROTIG, with 275 (31%) classified in the dropout group. Of the patient population, 65.5% (n = 582) self-identified as transgender women, while 34.5% (n = 306) identified as transgender men. Significant differences were noted between the dropout and non-dropout groups. Specifically, differences were noted among transgender women (p < 0.001), individuals with lower levels of education (p < 0.001), those with fewer diagnoses classified under ICD-10 as F64 (p < 0.001), individuals exhibiting fewer clinical comorbidities recorded in ICD-10 (p < 0.001), and those who commenced inclusion in PROTIG after 2010 (p < 0.001).

Conclusion

There exists a notable rate of treatment discontinuation among individuals receiving care at PROTIG, with statistically significant variances observed between groups. We posit potential rationales for this discontinuation, informed by care experiences and feedback from group attendees: Increased accessibility to outpatient services in our jurisdiction for Transgender Care, along with heightened societal awareness of gender identity fostering diverse gender expression avenues devoid of reliance on gender-affirming surgical interventions.

Prevalence of suicidal thoughts and attempts in the transgender population of the world: a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to determine global pooled prevalence of suicide thoughts and attempts in transgender population.

METHODS

For doing comprehensive search strategy related to objectives in the presence meta-analysis, all international databases like PubMed (Medline), Scopus, Embase, Web of Sciences, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINHAL) were searched from January 1990 to December 2022. The quality of the final selected studies was evaluated according to Newcastle-Ottawa Quality Assessment Scale for cross-sectional studies. The subgroup analysis was done based on type of transgender (female to male, male to female) and prevalence (point, period, and lifetime), country, and criteria of diagnosis. All analysis was done in STATA version 17.

RESULTS

From the total number of 65 selected studies, 71 prevalence of suicidal thoughts, including point, period, and lifetime prevalence were extracted and combined. After combining these values, the prevalence of suicidal thoughts in the transgender population in the world was 39% in the past month (pooled point prevalence: 39%; 95% CI 35-43%), 45% in the past year (pooled period prevalence: 45%; % 95 CI 35-54%) and 50% during lifetime (pooled lifetime prevalence: 50%; % 95 CI 42-57%). Also, the prevalence of suicide attempt in the transgender population of the world was 16% in the past month (pooled point prevalence: 16%; 95% CI 13-19%), 11% in the past year (pooled period prevalence: 11%; % 95 CI 5-19%) and 29% during lifetime (pooled lifetime prevalence: 29%; % 95 CI 25-34%).

CONCLUSION

The present meta-analysis results showed the prevalence of suicidal thoughts and attempts in the transgender community was high, and more importantly, about 50% of transgenders who had suicidal thoughts, committed suicide.

Factors Associated with Suicidal Ideation and Suicide Attempt in Brazilian Transgender Youth

The rates of suicidal ideation and suicide attempts among transgender youths are high. However, in Brazil, there are no studies about these outcomes in this population. The present study aims to investigate the prevalence of suicidal ideation and suicide attempts in Brazilian transgender youths (binary and non-binary), in association with predictor variables, following the Minority Stress Theory. The predictor variables analyzed were depressive symptoms, discrimination, gender distress, deprivation, social support, and gender identity support from parents and friends. Participants were recruited through an online survey. The final sample consisted of 213 participants, aged 13 to 25 years old. Two equal regression analyses were performed, one for each outcome. Out of the total, 103 (48.6%) identified as transgender boys, 44 (20.8%) as transgender girls, and 65 (30.7%) as non-binary. The mean age was 18.53 years (SD 2.50). The study found that 57.6% of the sample had depressive symptoms, 72.3% experienced suicidal ideation, and 42.7% had attempted suicide. In the final model, the variables that were associated with suicidal ideation were deprivation, gender distress, and depressive symptoms. As for suicide attempts, the variables deprivation and depressive symptoms were correlated. Further studies on this population should be conducted to analyze protective factors for these outcomes.

Health challenges in the LGBTI+ population in Brazil: a scenario analysis through the triangulation of methods

Abstract This article aims to reflect on the current health challenges of lesbians, gays, bisexuals, transgenders, intersex, and other sexual and gender minorities (LGBTI+) within the Brazilian scenario. This study adopted a triangulation approach, based on two studies developed in the Southeast and South of Brazil, which included policy analysis and qualitative research on the perceptions of key actors from the Brazilian Unified Health System (SUS) - LGBTI+ users, workers, and managers. All data were analyzed by an interdisciplinary team of researchers. The main problems faced by the LGBTI+ population were registered, indicating some of the necessary progress. Some of these challenges include: access of the LGBTI+ population to SUS; the need to train health professionals; the decentralization of health services sensitive to the LGBTI+ population; the distinct forms of violence and discrimination; the lack of research in health care conducted with specific groups, such as lesbians, bisexuals, intersex, and other sexual minorities. The results reinforce the urgency for the complete implementation of the “National Policy for the Comprehensive Health of LGBT”. The recognition of the LGBTI+ health needs will aid in achieving the principles which are the guiding principles of SUS.

Health challenges in the LGBTI+ population in Brazil: a scenario analysis through the triangulation of methods

This article aims to reflect on the current health challenges of lesbians, gays, bisexuals, transgenders, intersex, and other sexual and gender minorities (LGBTI+) within the Brazilian scenario. This study adopted a triangulation approach, based on two studies developed in the Southeast and South of Brazil, which included policy analysis and qualitative research on the perceptions of key actors from the Brazilian Unified Health System (SUS) - LGBTI+ users, workers, and managers. All data were analyzed by an interdisciplinary team of researchers. The main problems faced by the LGBTI+ population were registered, indicating some of the necessary progress. Some of these challenges include: access of the LGBTI+ population to SUS; the need to train health professionals; the decentralization of health services sensitive to the LGBTI+ population; the distinct forms of violence and discrimination; the lack of research in health care conducted with specific groups, such as lesbians, bisexuals, intersex, and other sexual minorities. The results reinforce the urgency for the complete implementation of the "National Policy for the Comprehensive Health of LGBT". The recognition of the LGBTI+ health needs will aid in achieving the principles which are the guiding principles of SUS.

Depression, Self-Esteem, and Resilience and its Relationship with Psychological Features of Sexuality among Transgender Men and Women from Brazil

This cross-sectional study investigated whether depression, self-esteem, and resilience (mental health indicators) are associated with some psychological features of sexuality (sexual fear, sexual anxiety, sexual dissatisfaction, and sexual body image worries) in a sample of 462 transgender men and women from Brazil. Pearson's correlations were performed between all continuous variables in the study. Those that were significantly associated with the psychological features of sexuality in previous analyses were tested as independent variables in multiple linear regression models. Sexual fear, sexual anxiety, sexual dissatisfaction, and sexual body image worries were negatively related to self-esteem and resilience, while positively related to depression. Higher levels of depression were associated with sexual fear, while higher levels of depression and lower self-esteem were associated with sexual anxiety. In addition, higher levels of depression and lower levels of resilience were associated with sexual dissatisfaction. Depression and resilience were associated with the composite score of sexual dissatisfaction and sexual anxiety. Our results suggest that negative mental health indicators may impair the sexual life of transgender individuals. Clinical interventions should be developed and tested to address the psychological features of sexuality.

Mental health in transgender individuals: a systematic review

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

Minority stress and the inner critic/oppressive sociocultural schema mode among sexual and gender minorities

Several adverse psychological outcomes among sexual and gender minorities (SGM) are well documented in the literature. Notwithstanding the emergence of these data, SGM still receive little attention regarding psychological interventions, which include Schema Therapy (ST), an emerging integrative psychotherapy approach. Even though revisions have been proposed to expand ST’s understanding of emotional needs, schemas, domains, and schema modes, there is a gap in our understanding of SGM. Based on that, the main goal of this theoretical essay is to propose a specific ST intervention for SGM, addressing sociocultural aspects aiming at promoting a healthy functioning that can interpose oppression and internalized prejudice. To this end, we will present (a) the minority stress theoretical framework; (b) the ST model applying to SGM clients; and (c) a few strategies of ST intervention for SGM clients, highlighting the need for strengthening individuals’ healthy schema mode. It should be noted that, despite clinical work being relevant, there are social variables supporting and maintaining maladaptive structures. We hope the therapeutic interventions proposed promote dialogue on this subject and encouraging positive societal changes.