Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Differences in risky sexual behaviors and HIV prevalence between men who have sex with men and transgender women in the Midwest Brazil

Men who have sex with men (MSM) and transgender women (TW) are disproportionally affected by HIV infection. This cross-sectional study evaluated the HIV-1/2 prevalence, risk factors and HIV molecular features of MSM and TW from Midwest Brazil. Four hundred and thirty participants (278 MSM and 152 TW) from Mato Grosso do Sul, Brazil, were interviewed and tested for HIV-1/2 infection between November 2011 and September 2013. Participants who were assigned male at birth, older than 18 years old and self-declared as MSM or TW were recruited from LGBT+ associations, as well as public (parks, square, streets, etc) and private [nightclubs, saunas, brothels, etc] places. The prevalence of HIV-1 was 14.4% (9.0% among MSM and 24% among TW; p<0.001). The factor independently associated with HIV-1 infection among MSM was being 30 years-old or older. Among TW, having suffered sexual coercion, lifetime syphilis infection and hepatitis C virus exposure were associated with HIV-1 infection. Phylogenetic analyses classified 65% sequences as subtype B and 35% as possible recombinants. All but one recombinant sample were from TW individuals. High HIV-1 prevalences were observed in both groups, highlighting the urgent need to devise specific HIV interventions targeting these key populations. Notably, TWs are more vulnerable to HIV infection, which was associated with sexual violence and co-infection with other STIs. With regard to MSM, being 30 years old or older was significanty associated to HIV, reinforcing the idea that MSM are less exposed [or exposed later] to STIs than TWs, although MSM are clearly more vulnerable than the general population.

Prevalence and Variations of Sexual Violence Victimization Among US-Based Latino Adults and Adolescents: A Systematic Literature Review

Sexual violence victimization (SVV) is a significant public health concern. SVV research often focuses on college-attending White women's experiences, resulting in a knowledge gap regarding the experiences of ethnic minority groups, including the Latino community - the largest minority group in the US. To develop more culturally sensitive SV prevention efforts, the current study reviewed research focused on the prevalence rates of SVV among Latino people. The authors searched for published articles in PubMed, PsycINFO, and the reference sections of relevant articles published from 2011 to 2022. Articles were deemed eligible if they presented SVV prevalence rates for Latino participants; 39 articles were included in the review. The most frequently assessed aspect of SVV among Latino people was whether they had ever been victimized. The average prevalence rate across articles was 16.0%. Additionally, researchers examined the prevalence rates of unwanted touching, sexual coercion, and completed rape among Latino individuals. Few articles examined SVV prevalence rates among sexual and gender minority Latinos; those that did found higher SVV rates among those groups. SVV is a prevalent issue within the Latino community, with women and sexual minorities facing an even greater risk. Moving forward, studying the contextual factors of SVV among Latino people and developing culturally sensitive interventions tailored to this population are needed.

"I would prefer to be dead than to live this way": Lived experiences of stigma and discrimination against khwaja sira in Swat, Pakistan

Due to their identification as third gender people, khwaja sira have historically been subjected to experiences of social marginalization. However, the extant literature has not fully explored the lived experiences of stigma and discrimination against khwaja sira in the Swat Valley of Khyber Pakhtunkhwa, Pakistan. To address this gap, we conducted 45 interviews with khwaja sira in Mingora, Swat, Khyber Pakhtunkhwa to better understand their experiences of gender-nonconformity stigma and discrimination in various social contexts, including within their families, in accessing health care, and within education and work contexts. Applying Minority Stress Theory and utilizing thematic content analysis, the present study identified three dimensions of gender-nonconformity stigma: (1) internalized stigma, namely feelings of shame and embarrassment; (2) perceived stigma, namely opinions others had of khwaja sira regarding lack of employability or engagement in sex work; and (3) enacted stigma, namely exclusion from families, in educational settings, in religious spaces, and in healthcare settings. Findings should inform future social intervention and community practice engagements with khwaja sira communities in Pakistan.

Sex work-related homicides: Insights from the National Violent Death Reporting System, 2012-2020

Homicide is a prevalent cause of death among sex workers, given their increased risk of violence due to proximity to criminal activities such as drug trade and human trafficking. This study analyzes homicide data from the National Violent Death Reporting System (NVDRS) covering 49 US states, the District of Columbia, and Puerto Rico from 2012 to 2020. Case inclusion criteria included: (1) manner of death of homicide, and (2) sex work-related circumstance. Descriptive analyses examined victim and injury characteristics, suspect information, and circumstances. The study identified 321 sex work-related homicides (54% female, 41% male, 6% transgender). Among female victims, 94% were sex workers, and 54% of their suspects were clients. Money conflicts (23%) and other crimes (30%), most often in progress, commonly precipitated homicides of female victims. Substance use problems were reported in 49% of female victims, with 25% of their suspected perpetrators reportedly using substances in the preceding hours. For male victims, 54% were clients and 9% were sex workers. Suspects in male homicides were primarily sex workers (34%) or individuals engaged in sex work-adjacent criminal activities (36%). Money conflicts (49%), other crimes (47%) most often in progress, and sex trafficking involvement (25%) commonly precipitated homicides with male victims. Transgender sex worker victims were mostly transfeminine (94%) and non-Hispanic black (89%). Money conflicts (78%) most commonly precipitated homicides among transgender sex worker victims. These findings can inform prevention strategies addressing underlying risk factors for persons involved in sex work.

Mediational pathways exploring the link between adverse childhood experiences and physical health in a transgender population

BACKGROUND

Adverse childhood experiences (ACEs) consist of instances of abuse, neglect, or household dysfunction occurring before adulthood. Prevalence rates of ACEs are higher among specific populations, including gender minorities. In addition to ACEs, transgender individuals (TG) face many personal, social, and structural factors that have the potential to negatively impact their physical health.

OBJECTIVE

This study examines exploratory mediational pathways between ACEs and two health outcomes (i.e., general health and days physically ill) in TG. Mediators include everyday discrimination, social support, gender non-affirmation, and mental distress.

METHODS

Cross-sectional data from the U.S. Transgender Population Health Survey (TransPop) was used to conduct a serial/parallel mediation analysis. The TransPop survey included a total of 274 TG.

RESULTS

For both outcome variables, the same three indirect pathways were significant. First, ACEs were associated with increased mental distress, which was associated with a decrease in general health and an increase in days physically ill. Second, ACEs were associated with increased discrimination, which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill. Finally, ACEs were associated with discrimination, which was associated with increased gender non-affirmation which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill.

CONCLUSION

Interventions focused on reducing discrimination, gender non-affirmation, and poor mental health may be vital to improving the health of TG and to mitigating the indirect role of ACEs on TG health.

First They Came for Us All: Responding to Anti-Transgender Structural Violence With Collective, Community-Engaged, and Intersectional Health Equity Research and Advocacy

This article is a call for collective action across health equity researchers and advocates to build a more just world. We attempt to make sense of senseless structural and interpersonal brutality in the context of the current political climate across the United States, whereby the spectrum of gender nonconformity has been and continues to be stigmatized. From drag performance to transgender identities to gender-affirming health care, extremists have instrumentalized primary levers of democracy-the courts, legislatures, and social media-to attempt to outlaw and eradicate gender expansiveness and those who provide forms of support and care, including gender-affirming medical care, to transgender, nonbinary, and gender-expansive (TNBGE) individuals.

Experiences of discrimination and support among trans men and women partnered with cis men

Trans individuals routinely experience discrimination. In this study, thirty-nine couples consisting of a trans partner and a cis male partner from the San Francisco Bay Area were interviewed about their relationship. The interviews were digitally recorded, transcribed and reviewed for accuracy. Guided by grounded theory, coders began thematic analysis until inter-coder reliability was achieved. Further qualitative coding produced several codes, two of which are focused upon here: namely, discrimination and support. This study highlights discrimination at the institutional level, such as being denied housing and employment, and at the interpersonal level, such as experiencing harassment from strangers and exclusion from queer community spaces. Trans individuals reported becoming desensitised to discrimination, moving to safer geographic locations, and acknowledged cis or straight passing as a privilege and a prevention tactic against discrimination, although this sometime left participants feeling their gender had been invalidated. Although most trans individuals sought support from their cis partners, some cis partners reacted with violence to discrimination, provoking the situation's severity and upsetting their trans partner. Transphobic discrimination is widespread, and it is crucial for frontline health and other service providers to understand the impact it has on both trans individuals and trans/cis couples, and for agencies to offer resources to support these relationships.

"There's Still Time to be Happy": The Life Trajectories of Portuguese Transgender Women Who Transitioned at 50+ Years

The process of transitioning involves making changes to align one's life with their authentic gender identity. This study explores the life trajectories of three Portuguese transgender women who transitioned later in life (50+ years old) by identifying key chapters in their life courses. Through inductive thematic analysis, six chapters were identified from the participants' interviews: (1) awareness of "something different in me," (2) locked into suffering, (3) finding comfort in something that is socially recognized, (4) "it is enough": it is time to recognize and embrace the woman I am, (5) living my life as a woman, and (6) building and leaving a legacy. Aging and the process of self-discovery played pivotal roles in participants' process of transitioning. The perception of finitude and the limitations associated with the time of life led them to realize that there was no time to waste and a sense of urgency to live authentically.

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

Depression, Anxiety, and Stress among the Malay Muslim Transgender Women in Northern Malaysia: A Mixed-Methods Study

The study aimed to determine the prevalence and associated factors of depression, anxiety, and stress among the Malay Muslim transgender women in the northwestern states of Peninsular Malaysia. This mixed-method, quantitative and qualitative, study was conducted in collaboration with a nongovernmental organization that works incognito to advocate and help transgender women. Participants were recruited using a snowball method. A self-administered questionnaire was used that included information related to the demographic background of participants, and the Depression, Anxiety and Stress Scale and Oslo-3 Social Support Scale. For the qualitative part of the study, 13 in-depth interviews were conducted using a semi-structured interview guide in the Malay language. The study showed the prevalence of depression, anxiety, and stress was 33.3% (n = 47), 48.2% (n = 68), and 26.2% (n = 37), respectively. Difficulty in finding employment was significantly associated with depression, anxiety, and stress, whereas a history of physical abuse was also significantly associated with anxiety, and being ostracized by friends was significantly associated with depression. During in-depth interviews, suicidal thoughts were mentioned by several respondents and many lamented poor support from family and cisgender friends, and they complained of societal pressure. In addition to being physically and verbally abused, some also complained about cyberbullying. There is an urgent need to identify those with mental distress among transgender women in Malaysia to enable early interventions. More research is needed to identify mental health issues among transgender women and highlight these issues to sensitize the general public to their problems.

Validation of the Patient Health Questionnaire-9 for Suicide Screening in Transgender Women

Purpose

High prevalence of depression in transgender women highlights the importance of validating the measure to assess depression. Moreover, depression is significantly associated with suicide across research studies. The aims of the current study were to validate a Chinese-language version of the Patient Health Questionnaire-9 (PHQ-9) and to assess operating characteristics of the PHQ-9 for suicide screening in transgender women.

Methods

With the approval of an Institutional Review Board (IRB), a total of 198 transgender women living in Shenyang, China, were recruited, and asked to complete the PHQ-9, including measures of their suicidal ideation, planning and attempt.

Results

A one-factor model of the PHQ-9 was supported in the current sample, showing good reliability and validity. The best cutoff point for the PHQ-9 in suicidal ideation was 17, with a sensitivity/specificity of 77.78%; the best cutoff point for PHQ-9 in suicidal planning was 17, with a sensitivity of 81.82% and a specificity of 73.26%; and the best cutoff point for PHQ-9 in suicidal attempt was 20, with a sensitivity of 75% and a specificity of 90.21%.

Conclusion

Findings supported the validity of the PHQ-9. With potential clinical or research application, the PHQ-9 can be an efficient instrument for suicide screening in transgender women.

Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic

Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.

Examining Differences in Substance Use Outcomes and Related Correlates among Transfeminine and Transmasculine Adults Using the 2017 New York State Patient Characteristics Survey

Background: Transgender persons in the U.S. experience high levels of violence and discrimination which have been linked to adverse substance use outcomes. Despite transgender women's higher exposure to such deleterious events compared to transgender men, studies have often aggregated both transgender women and men, obfuscating potentially unique differences between these groups. The current study, guided by the Minority Stress Model, examines differences in substance use outcomes and related correlates among transfeminine and transmasculine adults. Methods: A secondary data analysis was conducted using the 2017 Patient Characteristics Survey of public mental health facilities in the state of New York (N = 1387). Controlling for theoretically relevant factors, logistic regression models were estimated to examine differences between transfeminine and transmasculine adults in alcohol-related disorder (ARD) and drug use-related disorder (DURD) diagnoses, and tobacco use. Correlates of substance use disparities were also examined within gender identity groups. Results: Overall, 35% of participants were documented as using tobacco products whereas 14 and 19% were diagnosed with ARDs and DURDs, respectively. Transfeminine participants were 1.44-times more likely to be diagnosed with ARDs relative to transmasculine adults. Compared to transmasculine and White participants, transfeminine and Black participants were 1.64- and 1.59-times more likely to be diagnosed with DURDs. Conclusions: Recognizing the observed higher hazardous substance use risk among transfeminine and Black participants, findings indicate the potential role of minority stress in health outcomes of stigmatized communities. Our findings emphasize the need for identifying prevention and treatment strategies aimed at mitigating the implications of minority stress.

Misgendering a transgender woman using FORDISC 3.1: A case study

•FORDISC was unable to classify a transgender woman despite her extensive gender-affirming medical care, including Facial Feminization Surgeries.•This case study demonstrates that there is a need for forensic anthropologists to educate themselves on cases that may involve transgender people.•The use of a biocultural approach will allow forensic anthropologists to better identify marginalized individuals, including transgender women.

Coping Strategies as a Moderator for the Association between Intimate Partner Violence and Depression and Anxiety Symptoms among Transgender Women

Evidence suggests that intimate partner violence (IPV) is associated with negative mental health outcomes. There is currently limited research on the impact of IPV on the outcomes of mental health for transgender women. The current study aimed to examine the relationship between intimate partner violence, coping skills, depression, and anxiety in a sample of transgender women. Hierarchical regression analyses were conducted examining the relationship of IPV and depression and anxiety symptoms, where coping skills moderate this relationship. The results suggest that those with experiences of IPV are more likely to have symptoms of depression and anxiety. For individuals with no experiences of IPV and low depression, high levels of emotional processing coping and acceptance coping buffered this relationship. For individuals with more experiences of IPV and more depressive symptoms, coping skills did not show to buffer this relationship. These same coping skills did not show evidence for buffering anxiety symptoms for transgender women with low or high levels of IPV. The results, implications, and limitations of this study and suggestions for further research are discussed.

The Impact of Stressful Life Events on Suicidal Ideation in Gender Dysphoria: A Moderator Effect of Perceived Social Support

Factors associated with suicidal ideation in the gender dysphoria population are not completely understood. This high-risk population is more likely to suffer stressful events such as assault or employment discrimination. This study aimed to determine the association of stressful events and social support on suicidal ideation in gender dysphoria and to analyze the moderator effect of social support in relation to stressful events and suicidal ideation. A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain that consisted of 204 individuals (51.7% birth-assigned males and 48.3% birth-assigned females), aged between 13 and 59 (M = 27.95 years, SD = 9.58). A Structured Clinical Interview, a list of 16 stressful events, and a functional social support questionnaire (Duke-UNC-11) were used during the initial visits to the unit. The data were collected between 2011 and 2012. A total of 50.1% of the sample have had suicidal ideation. The following stressful events were associated with suicidal ideation: homelessness, eviction from home, and having suffered from physical or verbal aggression. Also, there was an inverse relation between perceived social support and suicidal ideation. There was a statistically significant interaction between a specific stressful event (eviction) and perceived social support. The study suggests that the promotion of safer environments could be related to lower suicidal ideation and that networks that provide social support could buffer the association between specific stressful events and suicidal ideation.

Intersectional stigma and gender non-affirmation hinder HIV care engagement among transgender women living with HIV in India

Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk

BACKGROUND

Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination.

SETTING

This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019.

METHODS

We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing).

RESULTS

Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services.

CONCLUSIONS

Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.

Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health

In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.

Prevalence and Determinants of Depressive and Anxiety Symptoms among Transgender People: Results of a Survey

OBJECTIVES

The aim was to investigate the prevalence of probable depression and probable anxiety and to investigate the determinants of depressive symptoms and anxiety symptoms among transgender people.

METHODS

In this "Transgender Survey" (n = 104) we included transgender people who had joined self-help groups to obtain and share information about the gender-affirming surgeries performed at the Division of Plastic, Reconstructive and Aesthetic Surgery at the University Medical Center Hamburg-Eppendorf. Data collection took place between April and October 2022. To measure probable depression, the patient health questionnaire-9 was used. The generalized anxiety disorder-7 was used to quantify probable anxiety.

RESULTS

The prevalence of probable depression was 33.3% and it was 29.6% for probable anxiety. Multiple linear regressions showed that both more depressive symptoms and anxiety symptoms were significantly associated with younger age (β = -0.16, p < 0.01; β = -0.14, p < 0.01), being unemployed (e.g., full-time employed compared to unemployment: β = -3.05, p < 0.05; β = -2.69, p < 0.05), worse self-rated health (β = -3.31, p < 0.001; β = -1.88, p < 0.05), and having at least one chronic disease (β = 3.71, p < 0.01; β = 2.61, p < 0.05).

CONCLUSIONS

Remarkably high prevalence rates were identified among transgender people. Furthermore, risk factors of poor mental health (e.g., unemployment or younger age) were identified-which can help to address transgender people at risk for poor mental health.

Students' knowledge, comfort, attitudes, and training on oral health of transgender individuals: A pilot study

PURPOSE

The purpose of this pilot study was to evaluate students' knowledge, comfort, attitudes, and formal training on oral health of transgender individuals.

METHODS

A single-site cross-sectional study of 223 students from four educational programs were invited to participate in this study. A 17-item survey was modified from two previous instruments with permission. The electronic survey was disseminated via Google Forms two times 6 weeks a part. Analyses were conducted using R version 4.1.1. Survey responses were summarized as means and standard deviations. Comparisons of survey responses by program type, age group, prior degree, and gender were performed using the chi-square test for association and analysis of variance.

RESULTS

A total of118 completed the survey for a 53% response rate. Students disagreed (26.3%) they had knowledge on hormone treatments or non-hormonal treatment (40.7%) and strongly disagreed (40.7%) they had knowledge on oral manifestations of hormonal or non-hormonal therapies. Students strongly agreed they are comfortable treating transgender patients (63.6%) and believe it is the responsibility of all healthcare providers to care for transgender patients (83.1%). Students disagreed they are prepared to care for transgender patients (40.7%) or that their faculty demonstrate competency caring for transgender patients undergoing hormonal treatment (21.4%).

CONCLUSION

Students are comfortable providing oral health care to transgender individuals and feel a responsibility to care for them. Formal training on hormonal and non-hormonal therapy for transgender individuals is needed in dental education programs to enhance students' knowledge and faculty competence.

Barriers to uptake of PrEP across the continuum among transgender women: A global scoping review

BACKGROUND

Although preexposure prophylaxis (PrEP) has demonstrated high efficacy for HIV prevention, rates of PrEP uptake remain low among the transgender population, especially in transgender women (TGW). We conducted this scoping review to assess and characterize barriers to PrEP use along the PrEP care continuum among TGW.

METHODS

We conducted this scoping review by searching studies in Embase, PubMed, Scopus, and Web of Science. Eligibility criteria included: reporting a PrEP related quantitative result among TGW; peer-reviewed and published in English between 2010-2021.

RESULTS

Globally, high willingness (80%) to use PrEP was found, yet uptake and adherence (35.4%) were low. TGW experiencing hardship, including poverty, incarceration, and substance use, were associated with higher odds of PrEP awareness but lower odds of PrEP use. Structural and social barriers such as stigma, medical mistrust, and perceived racism can be important barriers for PrEP continuation. High social cohesion and hormone replacement therapy were associated with greater odds of awareness. In addition, our study confirmed prior research showing that PrEP does not lower feminizing hormone levels in TGW.

CONCLUSIONS

Significant demographic factors among TGW that are associated with PrEP engagement. It is imperative to focus on TGW as a population with independent needs, requiring specific PrEP care guidelines and tailored resource allocation, that fully considers individual-, provider-, and community/structural-level barriers and facilitators. The present review also indicates that combining PrEP care with GAHT or broader gender-affirmation care may facilitate PrEP use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transnational Trans Woman Inspires and Informs Evidence-Informed Interventions

Transitional Care Coordination is an evidence-informed model program developed by New York City Correctional Health Services as a Health Resources and Services Administration Special Projects of National Significance Correctional Health Linkage Intervention. Using implementation science under this and subsequent demonstration projects, interventions were adapted and enhanced to address the transitional needs of people of Puerto Rican ancestry and to expand the network of care across the islands of Puerto Rico. These interventions were informed, in part, by a transnational trans woman of color of Puerto Rican ancestry living with HIV. A socioecological model framework and case study are used to illustrate how evidence-informed interventions are developed and adapted to address the needs of those served.

Implementing Gender-Affirming Care in Correctional Settings: A Review of Key Barriers and Action Steps for Change

Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration, interpersonal violence, HIV and other sexually transmitted infections, substance use disorders, and suicidality. Little is known about successful approaches to improve health outcomes for TGD individuals impacted by incarceration. We review the barriers to providing gender-affirming clinical care in correctional systems in the United States, identify key knowledge gaps regarding the provision of gender-affirming care to incarcerated TGD populations, and highlight necessary steps to improve the health and safety of this highly vulnerable population. We also describe the components of a gender-affirming care model implemented in a state correctional facility, including support from correctional administrators, identifying a gender-affirming care provider, standardizing clinical care protocols, and adapting clinical services to TGD population needs. Similar models should be employed elsewhere to improve health outcomes for TGD populations during incarceration and on release.

A trans agent of social change in incarceration: A psychobiographical study of Natasha Keating

OBJECTIVES

This psychobiography focuses on the advocacy work of Natasha Keating, a trans woman incarcerated in two male prisons in Australia between 2000 and 2007. Incarcerated trans women are a vulnerable group who experience high levels of victimization and discrimination. However, Natasha advocated for her rights while incarcerated and this advocacy contributed to substantial changes in the carceral system. This psychobiography uses psychological understandings of resilience as well as the Transgender Resilience Intervention Model (TRIM) to investigate the factors that enabled this advocacy.

METHOD

Data consisted of an archive of letters written by Natasha and interviews with individuals who knew her well. This psychobiography was guided by du Plessis' (2017) 12-step approach and included the identification of psychological saliencies and the construction of a Multilayered Chronological Chart.

RESULTS

Natasha's life is presented in four chapters, with each chapter including a discussion of resilience based on the TRIM.

CONCLUSIONS

The TRIM suggests that during incarceration, Natasha was able to access more group-level resilience factors than at any other time in her life. This, combined with individual resilience factors, enabled her advocacy. This finding has implications for advocacy in general as it highlights the importance of both individual- and group-level factors in enabling individuals to effectively advocate for change in their environments.

Developing the "Oppression-to-Incarceration Cycle" of Black American and First Nations Australian Trans Women: Applying the Intersectionality Research for Transgender Health Justice Framework

Trans women are disproportionately incarcerated in the United States and Australia relative to the general population. Stark racial and ethnic disparities in incarceration rates mean that Black American and First Nations Australian trans women are overrepresented in incarceration relative to White and non-Indigenous cisgender and trans people. Informed by the Intersectionality Research for Transgender Health Justice (IRTHJ) framework, the current study drew upon lived experiences of Black American and First Nations Australian trans women to develop a conceptual model demonstrating how interlocking forces of oppression inform, maintain, and exacerbate pathways to incarceration and postrelease experiences. Using a flexible, iterative, and reflexive thematic analytic approach, we analyzed qualitative data from 12 semistructured interviews with formerly incarcerated trans women who had been incarcerated in sex-segregated male facilities. Three primary domains-pathways to incarceration, experiences during incarceration, and postrelease experiences-were used to develop the "oppression-to-incarceration cycle." This study represents a novel application of the IRTHJ framework that seeks to name intersecting power relations, disrupt the status quo, and center embodied knowledge in the lived realities of formerly incarcerated Black American and First Nations Australian trans women.

The Interactions Between Vulnerabilities for HIV and Syphilis among Cisgender and Transgender People Who Use Drugs

In Brazil, transgender people are most affected by HIV, and crack cocaine addiction may contribute to social vulnerability and exposure to sexual and violence-related risks. This cross-sectional study comprised 2393 individuals seeking addiction treatment, consisting of 43 trans women, 1995 cisgender men, and 355 cisgender women. Records of rapid test results for HIV and syphilis and screening responses of trans women were compared to both cisgender groups using a logistic regression model to identify associated risk factors. HIV prevalence was higher in the transgender group (39.5%) than in cis women and men (5.9% and 3.6%, respectively). Our study showed an eightfold higher chance of a positive HIV test among transgender individuals who used drugs (OR: 8.79, p < .01, 95% CI: 3.90-19.78) compared to cisgender people who used drugs. A lifetime history of syphilis infection was more common in transgender people (60.0%) and cis women (32.8%) than in cis men (9.5%). Active syphilis was also more common in the transgender population (OR: 5.46, p < .01, 95% CI: 2.63 11.32). In our sample, 44.2% of transgender individuals had a history of at least one suicide attempt in their lifetime. Our results showed that transgender women were at higher risk of crack cocaine use (OR: 5.51, p < .01, 95% CI: 2.16-14.06) than cisgender men and women. The study showed that trans women had a higher prevalence of syphilis and HIV, and a greater chance of being homeless. The synergy of these vulnerabilities may have led to our findings of high psychotic symptoms and a history of suicide attempts in transgender individuals.

Clinical and Behavioral Outcomes for Transgender Women Engaged in HIV Care: Comparisons to Cisgender Men and Women in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) Cohort

Describe health of transgender women (TW) with HIV vs. cisgender men and women (CM, CW) in a U.S. HIV care cohort. Data were from Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2005-2022. TW were identified using clinical data/identity measures. PWH (n = 1285) were included in analyses (275 TW, 547 CM, 463 CW). Cross-sectional multivariable analyses compared HIV outcomes/co-morbidities between TW/CM and TW/CW, and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated. TW had poorer adherence (> 90% adherent; aOR 0.57; 95%CI 0.38, 0.87) and were more likely to miss ≥ 3 visits in the past year than CM (aOR 1.50, 95%CI 1.06, 2.10); indicated more anxiety compared to both CM and CW (p ≤ 0.001, p = 0.02); hepatitis C infection (p = 0.03) and past-year/lifetime substance treatment (p = 0.004/p = 0.001) compared to CM; and substance use relative to CW. TW with HIV differed in HIV clinical outcomes and co-morbidities from CM and CW.

Social Support as a Buffer of the Association between Sexual Assault and Trauma Symptoms Among Transgender and Gender Diverse Individuals

The prevalence of experiencing sexual assault is alarmingly high among Transgender and Gender Diverse people (TGD; people whose gender identities and/or expressions are not traditionally associated with their sex assigned at birth) and is associated with various mental health sequalae. Perceived social support has been shown to abate the negative outcomes of sexual assault among cisgender individuals, yet little is known about this association among TGD people, especially which provider of support (i.e., family, friends, or significant others) may be most beneficial. To that end, 191 TGD adults were recruited through Amazon's Mechanical Turk to examine perceived social support as a potential moderator of the association between sexual assault victimization and post-sexual assault trauma symptomology. Results showed an interaction trending toward significance between sexual assault and support from a significant other. Decomposition of this interaction demonstrated that sexual assault was associated with post-assault trauma symptoms when support from a significant other was low (ß = .25, p < .05) but not high (ß = .10, p = .089). The interaction between sexual assault and perceived social support was not significant for perceived support from friends (p = .133) or family (p = .954). Findings highlight the need for additional research on perceived social support as a potential buffering mechanism between sexual assault and post-assault symptomology in TGD people.

Social Networks Play a Complex Role in HIV Prevention Knowledge, Attitudes, Practices, and the Uptake of PrEP Through Transgender Women Communities Centered Around Three "Casas Trans" in Lima, Peru: A Qualitative Study

Transgender women's (TW) social networks may facilitate HIV prevention information dissemination and normative reinforcement. We conducted a qualitative study of social networks among 20 TW affiliated with 3 "casas trans" (houses shared among TW) in Lima, Peru, using diffusion of innovations theory to investigate community-level HIV prevention norms. Participants completed demographic questionnaires, social network interviews, and semistructured in-depth interviews. Median age was 26 and all participants engaged in sex work. Interviews revealed high HIV prevention knowledge and positive attitudes, but low engagement in HIV prevention. Respondents primarily discussed HIV prevention with other TW. Network members' opinions about pre-exposure prophylaxis (PrEP) frequently influenced respondents' personal beliefs, including mistrust of healthcare personnel, concern that PrEP efficacy was unproven, fear of adverse effects, and frustration regarding difficulty accessing PrEP. Patterns of influence in TW networks may be leveraged to improve uptake of HIV prevention tools, including PrEP.

Impact of Social Support on Suicidal Ideation and Attempts Among Gender Minority Adults

This study examined the impact of social support from family, non-gender minority friends, gender minority friends, and religious groups on suicidal ideation, suicide attempt history, and the number of suicide attempts. Researchers hypothesized that these types of social support were associated with lower suicidal thoughts and behaviors. This research is a secondary analysis of the Virginia Transgender Health Initiative Survey (THIS) data set (N = 350). Logistic regressions assessed suicidal ideation and attempts. Linear regression assessed the number of suicide attempts. Age was a covariate in all analyses. Social support from family (B = -.419, SE = .119, p < .001) was negatively associated with suicidal ideation and was not associated with an attempt history or number of attempts. This finding suggests that increasing social support from family may be an important factor to consider for suicide prevention for gender minority individuals.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda

BACKGROUND

The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking.

METHODS

A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0.

RESULTS

The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV.

CONCLUSION

The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

"What will we do if we get infected?": An interview-based study of the COVID-19 pandemic and its effects on the health and safety of sex workers in the United States

Emerging evidence suggests that sex workers face unique and profound risks arising from the COVID-19 pandemic. To illuminate the pandemic's effects on sex worker health and safety and identify intervention opportunities, from May-August 2020 in-depth interviews were conducted with a purposive sample of 15 sex workers, four service providers and two individuals who were both. Sampled sex workers included eight people of color, eight cisgender women, five cisgender men, three non-binary people, and one transgender woman. Using Conservation of Resources Theory to define impacts on sex worker resources and resulting health and safety implications, a deductive thematic analysis was conducted. Seven resources were threatened due to the pandemic: work opportunity, sex work venues, social support, health services, money, food, and housing. The loss of these resources was exacerbated by stigma - notably sex work criminalization - and significantly undermined health and safety by increasing food and housing instability, increasing risks of violence, and diminishing safer sex negotiation. Six resources were activated in response: social support, digital skills, health knowledge, non-sex work employment, money, and resilience. While social support had numerous benefits, investing digital skills and non-sex work employment were generally of limited impact. The pandemic's negative health and safety effects were most profound at the intersections of race, gender, class, and migration status. These findings suggest sex workers need urgent and ongoing support, with investments in social support and sex work decriminalization likely to have the greatest effects on health and safety relative to and beyond the COVID-19 pandemic.

Victimization Within and Beyond the Prison Walls: A Latent Profile Analysis of Transgender and Gender Diverse Adults

Background: Transgender and gender diverse (TGD) people are disproportionately incarcerated in the United States relative to the general population. A dearth of quantitative research has explored victimization as a risk factor for incarceration as well as the victimization experiences of formerly incarcerated TGD populations. Methods: In 2019, 574 TGD adults completed an online survey assessing sociodemographics, victimization across settings, and incarceration history. Latent class analysis was used to identify two sets of latent subgroups based on respondent's victimization experiences: 1) lifetime victimization (low; moderate; and high) and 2) classes of victimization while incarcerated (low; moderate; and high). Bivariate and multivariable logistic regression analyses examined sociodemographic, mental health, and lifetime victimization experiences associated with lifetime incarceration (Outcome 1). Among those with incarceration histories, bivariate hierarchical logistic regression analyses also explored the association between gender identity, race/ethnicity, HIV status, visual gender non-conformity, and class of victimization during incarceration (Outcome 2) . Results: Participants' mean age was 31.4 (SD = 11.2), 43.4% had a non-binary gender identity, 81.5% were White, non-Hispanic, 2.1% were living with HIV, and 13.2% had been incarcerated. In the multivariable model for Outcome 1, high levels of victimization, age, being a racial/ethnic minority, being a trans woman, living with HIV, and past-12-month polysubstance use were all associated with increased odds of lifetime incarceration (p-values < 0.05). In the bivariate hierarchical logistic regression analyses for Outcome 2, living with HIV and having a visually gender non-conforming expression were significantly associated with elevated odds of experiencing high levels of victimization while incarcerated (p-values < 0.05). Conclusion: Findings document the relationships between victimization and incarceration among TGD people as well as identify the subpopulations at greater risk for incarceration and experiencing victimization while incarcerated. Efforts are needed to prevent victimization across the life course, including while incarcerated and support TGD individuals in coping with the negative sequelae of victimization and incarceration experiences.

Transgender and gender expansive emerging adults: The moderating role of thwarted belongingness on mental health

Transgender and gender expansive emerging adults experience multiple forms of gender minority stress, which affect their mental health and wellbeing. Belongingness has been identified as a factor that fosters resilience among this population, with potential protective effects. Few studies have explored the role of thwarted belongingness and its potential moderating effect on the relation between gender minority stress and mental health. This study recruited a sample of 93 transgender and gender expansive emerging adults between the ages of 18 and 21 to examine whether thwarted belongingness significantly moderates the relations between gender minority stressors and mental health symptoms. We found evidence that thwarted belongingness moderates the relation between social rejection and depressive symptoms and the interaction effect between thwarted belongingness and victimization was significantly associated with psychological stress. For both of these associations, high levels of thwarted belongingness amplified the positive relation between gender minority stress and mental health symptoms. In contrast, at low levels of thwarted belongingness, the relation between rejection and depression was negative and the association between victimization and psychological stress was no longer statistically significant. Findings suggest that factors that minimize or interrupt thwarted belongingness among transgender and gender expansive emerging adults may be points of intervention to improve mental health outcomes in this population.

Sexual and gender minority university students in the wake of COVID-19: Unique risks and opportunities for intervention

Emerging adulthood is a critical period of development as individuals explore their identities and embark on developmental trajectories. Emerging adulthood may be an especially important period for sexual and gender minority (SGM) individuals as they explore, learn, and seek out communities related to their sexuality and gender identity. College is a unique setting in which SGM students may have access to physical and mental healthcare, secure food and housing, and affirming spaces and community related to their identity. However, the COVID-19 pandemic has interrupted or ended many of the services and resources provided by colleges and universities, potentially exacerbating challenges faced by sexual and gender minority students. This article provides recommendations for colleges and universities to improve access to and mitigate potentially negative outcomes among SGM students during and in the wake of the COVID-19 pandemic.

Mental health and substance use risks and resiliencies in a U.S. sample of transgender and gender diverse adults

PURPOSE

Victimization contributes to mental and behavioral health inequities among transgender and gender diverse (TGD) people, but few studies have simultaneously examined health-promoting resiliencies. We sought to identify classes of risk and resilience among TGD adults, assess characteristics associated with these classes, and examine their relationship with mental health and substance use outcomes.

METHODS

Cross-sectional data were from the 2015 US Transgender Survey, a non-probability study including 26,957 TGD adults. Using latent class analysis, we classified patterns of vulnerability and resilience based on risk (past-year denial of equal treatment, verbal harassment, physical attack, bathroom-related discrimination; lifetime sexual assault, intimate partner violence) and protective (activism; family, work, classmate support) factors. Regression models were fit to (1) determine the association between sociodemographic and gender affirmation characteristics and latent classes; (2) model associations between latent classes and mental health (current serious psychological distress, past-year and lifetime suicidal thoughts and attempts, and lifetime gender identity/transition-related counseling) and substance use (current binge alcohol use, smoking, illicit drug use; past-year drug/alcohol treatment) outcomes.

RESULTS

Three latent classes were identified: high risks, with activism involvement ("risk-activism," 35%); low risks, with not being out about one's TGD identity ("not-out," 25%); and low risks, with high family support ("family-support," 40%). Gender affirmation and sociodemographic characteristics, such as race/ethnicity and sexual orientation, were associated with latent classes. Risk-activism class membership was associated with higher odds of negative mental health and substance use outcomes, while the family-support class had lower odds of these outcomes.

CONCLUSIONS

Interventions leveraging family support, and policy protections from discrimination and victimization, may promote TGD mental and behavioral health.

Experiential Avoidance and Emotion Dysregulation as Mediators in the LGBTQ Minority Stress Model

Gender and sexual minorities are at increased risk for psychological disorders compared to the general population. The minority stress model has been proposed to explain these elevated rates of psychological distress. Per this model, minority stress factors (e.g., prejudice, discrimination, rejection, internalized homophobia/ transphobia) combine to create a unique stress which negatively impacts the mental health of gender and sexual minority individuals. With support for the general minority stress model established, attention has turned to investigating possible mediators in this model. In other words, how does minority stress cause psychological distress and negative mental health outcomes? The aim of the present study was to investigate experiential avoidance and emotion dysregulation as potential mediators in the relationship between minority stress factors and psychological distress. Final parallel mediation models supported that experiential avoidance and emotion dysregulation were significant mediators in the relationship between minority stress variables and psychological distress. These final models support that minority stress experiences, experiential avoidance, and emotion dysregulation are all factors that contribute to psychological distress in gender and sexual minority individuals. The implications of these findings are discussed.

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.

"Trans-forming" dental practice norms: Exploring transgender identity and oral health implications

OBJECTIVE

This narrative review explores current research to broaden understanding and awareness of the transgender experience while identifying oral health needs and proposing strategies of inclusivity to optimize oral health outcomes.

METHODS

A comprehensive electronic literature search was conducted in the following online databases: PubMed, Google Scholar, CINAHL, and Education Source. The search yielded 35 articles with a wide range of study designs and methodologies.

RESULTS & DISCUSSION

Several themes emerged from the literature, including psychosocial oral health implications, barriers to oral health care, inclusive dental practice strategies, and cultural competence of oral health providers.

CONCLUSION

The transgender population experiences many social and health disparities that stem from discrimination. Systemic inequalities, coupled with other barriers to care, have significant oral health implications for this population. Implementing inclusivity strategies and gaining awareness of the transgender experience will contribute to better oral health outcomes in this community.

Factors associated with symptoms of major depression disorder among transgender women in Northeast Brazil

INTRODUCTION

Transgender women (TGW) are one of the most vulnerable groups, including higher prevalence of HIV and mental health disorders, such as anxiety and depression than in the general population. Major Depression Disorder (MDD) is one of the most important mental health conditions due to an increasing trend in prevalence in the general population. This study aims at describing the prevalence of symptoms of MDD (SMDD) and associated factors among TGW in capitals of three States in Northeast Brazil.

METHODS

TGW n = (864) were selected from the cities of Salvador (n = 166), Recife (n = 350), and Fortaleza (n = 348) using Respondent Driven Sampling methodology. Symptoms of MDD were defined according to the Patient Health Questionnaire-9 scale. Multinomial logistic regression was used to compare those with mild/moderate or moderately severe/severe symptoms of depression with those with no depression, respectively, using complex sample design. Weighted Odds Ratio with 95% confidence interval were estimated.

RESULTS

51.1% of the sample was classified as mild/moderate and 18.9% as moderately severe/severe SMDD. Mild/moderate SMDD was associated with a history of sexual violence (OR = 2.06, 95%CI: 1.15-3.68), history of physical violence (OR = 2.09, 95%CI: 1.20-3.67),) and poor self-rated quality of life (OR = 2.14, 95%CI: 1.31-3.49).). Moderately severe/severe SMDD was associated with history of sexual violence (OR = 3.02, 95%CI: 1.17-7.77), history of physical violence (OR = 4.34, 95% CI:1.88-6.96), poor self-rated quality of life (OR = 3.32, 95%CI:1.804-6.12), lack of current social support (OR = 2.53, 95%IC: 1.31-4.88) and lack of family support in childhood (OR = 2.17, 95%IC 1.16-4.05)).

CONCLUSIONS

Our findings strengthens the evidence of a higher prevalence of SMDD among TGW as compared to the general population. Public health policies and actions that target social determinants of risk and protection for MDD among TGW must be urgently implemented.

Randomized Controlled Trial of Healthy Divas: A Gender-Affirming, Peer-Delivered Intervention to Improve HIV Care Engagement Among Transgender Women Living With HIV

BACKGROUND

Transgender women are disproportionately affected by HIV and are less likely to be optimally engaged in care than other groups because of psychosocial challenges. With community collaboration, we developed Healthy Divas, an individual-level intervention to increase healthcare empowerment and gender affirmation to improve engagement in HIV care. Healthy Divas comprises 6 peer-led individual sessions and one group workshop facilitated by a healthcare provider with expertise in HIV care and transgender health.

SETTING/METHODS

To test the intervention's efficacy, we conducted a randomized controlled clinical trial in San Francisco and Los Angeles among transgender women living with HIV; control was no intervention. Transgender field staff conducted recruitment. Assessments occurred at baseline and 3, 6, 9, and 12 months postrandomization. The primary outcome was engagement in HIV care, defined as the sum of (1) self-reported HIV care provider visit, past 6 months, (2) knowledge of most recent CD4 count, (3) self-reported antiretroviral therapy adherence ≥90%, and (4) self-reported antiretroviral therapy adherence ≥80%.

RESULTS

We enrolled 278 participants; almost half (46%) were African American/Black and one-third (33%) were Hispanic/Latina. At 6 months, participants in the intervention arm had over twice the odds of being in a higher HIV care engagement category than those in the control arm (aOR = 2.17; 95% CI: 1.06 to 4.45; P = 0.04); there were no significant study arm differences in the outcome at the other time points.

CONCLUSIONS

This trial demonstrates the short-term efficacy of an urgently needed behavioral intervention to improve engagement in HIV care among transgender women living with HIV; ongoing intervention may be needed to maintain positive impact over time.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03081559.

Mental health service utilisation among transgender women sex workers who are at risk of mental health problems in Shenyang, China: An application of minority stress theory

Transgender women sex workers (TGSW), as a highly stigmatised population, are at substantial risk for mental health problems but lack access to mental health care. This study investigated factors of mental health service utilisation (MHSU) behaviour and related behavioural intention among TGSW who were at risk of mental health problems in the past year [subsample 1: scored above the cut-off for probable depression or probable anxiety or had suicidal ideation (N = 126); subsample 2: perceived needs for mental health services (N = 109)]. A cross-sectional survey was conducted among TGSW in Shenyang, China during 2017-2018. Data on minority stress, coping, mental health and MHSU were collected. 10.3% of participants in subsample 1 and 14.7% in subsample 2 had sought help from mental health professionals in the last year. Unwillingness to disclose minority identity and gender non-affirmation were negatively associated with MHSU. Factors for behavioural intention of MHSU included unwillingness to disclose minority identity and social support for both subsamples and adaptive coping for subsample 2. Confidentiality concern, discrimination and cost were the most frequently endorsed barriers to mental health services. Interventions should promote gender affirmation, social support and adaptive coping as well as remove stigma to increase health service access and utilisation among minority populations.

Polyvictimization, Sex Work, and Depressive Symptoms Among Transgender Women and Men Who Have Sex With Men

This article examined the association among polyvictimization, sex work, and depressive symptomology among transgender women and men who have sex with men (MSM) in India. Data comes from a cross-sectional epidemiological study with 1,366 transgender women (from three states) and 2,182 MSM participants from five states of India. Multivariate regressions were used to examine how polyvictimization and sex work are associated with depressive symptoms. In total, 70% of transgender women and 44% of MSM participants in the sample reported being in sex work; 30% of transgender women and 17% of MSM reported at least one experience of abuse in last 6 months. In bivariate analysis, transgender women in sex work were more likely to report sexual abuse, and MSM in sex work more likely to report all types of abuse (physical, sexual, verbal, and property), compared to their peers. In multivariate models (with transgender women and MSM), increase in endorsement on types of abuses (polyvictimization) and being in sex work were associated with higher odds of reporting depressive symptoms. Both models controlled for age and marital status, while the model with transgender women also controlled for gender transitioning, and the model with MSM controlled for identity typology. National intervention program on HIV risk reduction must prioritize victimization screening and crisis management as part of their work. In addition, the interventions must be responsive to the diversity of the population, including those who engage in sex work, and address issues of access and support to gender transitioning services, and focus on psychosocial interventions to reduce stress due to gender-based stigma and discrimination among transgender women and MSM.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

Serological Confirmed Syphilis Among Transgender Women in Dominican Republic

Purpose

Transgender women (TW) in the Dominican Republic (DR) are at high risk for syphillis infection. Although treatable, infection rates remain at epidemic proportions.

Methods

In 2016, we conducted a national survey, with serological sampling of TW in the DR (n=255).

Results

In our sample, syphillis seropositivity was 47.45%. There was a statistically significant association between age (t=-2.93, df, p<0.01), arrest history (χ ²=8.15, p<0.01), exposure to violence (χ ²=3.73, p<0.05), and syphilis seropositivity. Multivariate analyses show TW arrested in the past 6 months have higher odds of seropositivity (odds ratio=2.05, confidence interval: 1.04-4.06, p<0.05).

Conclusions

There is a need for education and public health campaigns focused on TW specifically.