Connecting the Dots: Examining Transgender Women’s Utilization of Transition-Related Medical Care and Associations with Mental Health, Substance Use, and HIV

February 1, 2015, 12:00 am

≫ Next: A Web 2.0 and Epidemiology Mash-Up: Using Respondent-Driven Sampling in Combination with Social Network Site Recruitment to Reach Young Transwomen

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Abstract

Findings on access to general healthcare for transgender people have emerged, but little is known about access to transition-related medical care for transwomen (i.e., hormones, breast augmentation, and genital surgery). Transgender women have low access to general medical care and are disproportionately at risk for substance use, mental illness, and HIV. We conducted an analysis to determine if utilization of transition-related medical care is a protective factor for health risks to transgender women and to investigate if care differs by important demographic factors and HIV status. A secondary analysis was conducted using data from a 2010 HIV surveillance study using respondent-driven sampling to recruit 314 transwomen in San Francisco. Survey-corrected logistic regression models were used to estimate odds ratios for six psychosocial health problems—binge drinking, injection drug use, anxiety, depression, suicidal ideation, and high-risk intercourse—comparing various levels of utilization of transition-related medical care. Odds ratios were also calculated to determine if utilization of transition-related medical care was related to less overlap of risk domains. We found that Latina and African American transwomen had significantly lower estimated utilization of breast augmentation and genital surgery, as did transwomen who identified as transgender rather than female. Overall, utilization of transition-related medical care was associated with significantly lower estimated odds of suicidal ideation, binge drinking, and non-injection drug use. Findings suggest that utilization of transition-related medical care may reduce risk for mental health problems, especially suicidal ideation, and substance use among transwomen. Yet, important racial/ethnic and gender identity disparities in utilization of transition-related medical care need to be addressed.

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A Web 2.0 and Epidemiology Mash-Up: Using Respondent-Driven Sampling in Combination with Social Network Site Recruitment to Reach Young Transwomen

October 26, 2015, 12:00 am

≫ Next: The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

≪ Previous: Connecting the Dots: Examining Transgender Women’s Utilization of Transition-Related Medical Care and Associations with Mental Health, Substance Use, and HIV

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Abstract

Respondent-driven sampling (RDS) peer referral has been proven to be an effective recruitment method for hard-to-reach populations; however, its application in diverse populations is limited. Recruitment occurred in two phases: RDS-only followed by development and implementation of an online social network strategy in combination with RDS peer referral (RDS + SNS). Compared to RDS-only, RDS + SNS reached a sample that was younger (χ² = 9.19, P = .03), more likely to identify with a non-binary gender identity (χ² = 10.4247, P = .03), with less housing instability (50.5 vs. 68.6 %, χ² = 9.0038, P = .002) and less sex work (19.7 vs. 31.4 %, χ² = 5.0798, P = .02). Additionally, we describe lessons learned as a result of implementing our online social network strategy. Our findings underscore the importance of integrating Internet-driven strategies to meet challenges in sample diversity and recruitment of young transwomen.

The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

April 26, 2016, 12:00 am

≫ Next: Examining the Effects of Transphobic Discrimination and Race on HIV Risk Among Transwomen in San Francisco

≪ Previous: A Web 2.0 and Epidemiology Mash-Up: Using Respondent-Driven Sampling in Combination with Social Network Site Recruitment to Reach Young Transwomen

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Abstract

Significant health disparities exist for transgender female (trans*female) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16–24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N = 216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95 % CI 1.4–5.0), depression (AOR, 2.6; 95 % CI 1.2–5.9), and stress related to suicidal thoughts (AOR 7.7, 95 % CI 2.3–35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95 % CI 1.2–10.8), PTSD (AOR 2.1; 95 % CI 1.1–4.2) and stress related to suicidal thoughts (AOR 4.3, 95 % CI 1.5–13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of trans*female youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.

Examining the Effects of Transphobic Discrimination and Race on HIV Risk Among Transwomen in San Francisco

September 1, 2017, 12:00 am

≫ Next: Low PrEP Awareness and Use Among People Who Inject Drugs, San Francisco, 2018

≪ Previous: The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

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Abstract

Transwomen, in particular transwomen of color (TWOC), are among the most vulnerable populations at risk for HIV. This secondary analysis is organized using a gender minority stress framework to examine the effects of transphobic discrimination and race on HIV risk factors. We describe the sample of 149 HIV- adult transwomen in San Francisco and use binary logistic regression to examine the relationship between levels of transphobic discrimination and TWOC status on binge drinking and condomless receptive anal intercourse (CRAI), controlling for potential confounders. Those with high levels of transphobic discrimination had 3.59 fold greater odds of engaging in binge drinking compared to those who reported a low level of transphobic discrimination (95% CI 1.284–10.034; P = 0.015). TWOC had nearly threefold greater odds of CRAI compared to white transwomen (95% CI 1.048–8.464; P = 0.040). We discuss implications for gender minority stress research and future interventions for this population.

Low PrEP Awareness and Use Among People Who Inject Drugs, San Francisco, 2018

May 1, 2020, 12:00 am

≫ Next: Awareness and Willingness to use HIV Pre-exposure Prophylaxis (PrEP) Among Trans Women in China: A Community-Based Survey

≪ Previous: Examining the Effects of Transphobic Discrimination and Race on HIV Risk Among Transwomen in San Francisco

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Abstract

We examined PrEP awareness and use among people who inject drugs (PWID) in San Francisco in 2018. Of 397 respondents not known to be HIV positive, 56.7% had heard of PrEP, 38.9% knew that PrEP can prevent HIV transmission from sharing injection equipment, 13.6% had discussed PrEP with a health care provider, and 3.0% had used PrEP in the last 12 months. All seven male PWID who had used PrEP were also men who had sex with men. There is urgent need to improve messaging on PrEP’s effectiveness for PWID and to tailor ways of engaging PWID in PrEP programs.

Awareness and Willingness to use HIV Pre-exposure Prophylaxis (PrEP) Among Trans Women in China: A Community-Based Survey

September 28, 2020, 12:00 am

≫ Next: Population-based HIV prevalence, stigma and HIV risk among trans women in Nepal

≪ Previous: Low PrEP Awareness and Use Among People Who Inject Drugs, San Francisco, 2018

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Abstract

China’s national guidelines call for increasing HIV pre-exposure prophylaxis (PrEP) use to reverse the epidemic in populations at highest risk. However, few data exist on PrEP awareness and willingness among trans women in China. Our research aim was to fill this data gap through a cross-sectional survey among trans women in Nanjing and Suzhou cities of Jiangsu province. Respondent-driven sampling (RDS) was used to recruit participants to gauge their awareness of and willingness to use PrEP. Logistic regression analysis was used to characterize associations with awareness of PrEP and willingness to use PrEP. Of 222 HIV-negative/unknown serostatus trans women, 33.3% were aware of PrEP and 49.1% were willing to use PrEP. PrEP awareness was associated with a university degree or above (adjusted odds ratio [AOR] 2.77, 95% CI 1.31–5.89) and not using alcohol with sex (AOR 2.02, 95% CI 1.00–4.09). Willingness to use PrEP was higher among trans women with one (AOR 3.56, 95% CI 1.68–7.54) or multiple sexual partners (AOR 2.53, 95% CI 1.24–5.15) compared to those with no partners. This study witnessed low awareness of PrEP, yet substantial willingness to use PrEP. Implementation research to identify ways to promote, scale up access, and assess effectiveness of PrEP for trans women is urgently needed in China.

Population-based HIV prevalence, stigma and HIV risk among trans women in Nepal

January 29, 2021, 12:00 am

≫ Next: Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race

≪ Previous: Awareness and Willingness to use HIV Pre-exposure Prophylaxis (PrEP) Among Trans Women in China: A Community-Based Survey

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Abstract

Background

Transgender women (trans women) in Nepal are underserved in the HIV response. Data are needed to determine the HIV prevalence disaggregated from other key populations and to identify the particular risks faced by this community. Trans women are marginalized around the world and research is also needed to determine the impact of stigma on HIV risk to inform trans-specific interventions.

Methods

In 2019, we conducted the first population-based HIV behavioral surveillance study of trans women disaggregated from other key populations using respondent driven sampling (RDS). We estimated the HIV prevalence for trans women, and bivariate and multivariate Poisson binomial regression models were constructed to examine the relationship between HIV risk and stigma.

Results

Trans women participants (N = 200) had a mean age of 33 years old (SD = 10.96). We found a weighted HIV prevalence of 11.3% (95% CI 6·82% - 18·13). We found that depression and anxiety (aPR 0.81; 95% CI 0.67–0.97; p = 0·02) and current engagement in sex work (aPR 1.31; 95% CI 1.01–1.71; p = 0·046) were significantly associated with greater prevalence of condomless receptive anal intercourse. We found that experienced stigma of ever being verbally abused due to gender identity was significantly associated with lower prevalence of depression and anxiety (aPR 0.42; 95% CI 0.20–0.87; p = 0·002). Feeling unaccepted in Nepali society and believing people thought they were a criminal because of their trans identity was significantly associated greater prevalence of current sex work (aPR 1.36; 95% CI 1.03–1.78; p = 0·03; aPR 1.45; 95% CI 1.03–2.07; p = 0.04). Every measure of experienced stigma assessed was significantly associated with greater prevalence of current engagement in sex work.

Conclusions

Trans women are highly stigmatized in Nepal, leading to individual and systems factors that impact their risk for HIV. Interventions are needed that support the economic and mental wellbeing of trans women to prevent their heighted risk of HIV from stigma.

Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race

June 2, 2021, 12:00 am

≫ Next: Improved PrEP Awareness and Use among Trans Women in San Francisco, California

≪ Previous: Population-based HIV prevalence, stigma and HIV risk among trans women in Nepal

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Abstract

Background

Trans women experience high rates of gender-based violence (GBV)—a risk factor for adverse health outcomes. Transphobic hate crimes are one such form of GBV that affect trans women. However, little is understood about factors that shape transphobic hate crimes and racial/ethnic variation in these experiences. To contextualize GBV risk and police reporting, we examined self-reported types and correlates of transphobic hate crimes by racial/ethnic group of trans women in the San Francisco Bay Area.

Methods

From 2016 to 2018, trans women participated in a longitudinal cohort study of HIV. Secondary data analyses (N = 629) examined self-reported experiences of transphobic hate crimes (i.e., robbery, physical assault, sexual assault, and battery with weapon) by race/ethnicity, and whether hate crimes were reported to the police. Chi-square tests and simple logistic regression examined demographic, sociocultural, and gender identity factors associated with transphobic violence experiences and police reporting.

Results

About half (45.8%) of participants reported ever experiencing a transphobic hate crime; only 51.1% of these were reported to the police. Among those who reported a hate crime experience, Black (47.9%) and Latina (49.0%) trans women reported a higher prevalence of battery with a weapon; White (26.7%) and trans women of “other” race/ethnicities (25.0%) reported a higher prevalence of sexual assault (p = 0.001). Having one’s gender questioned, history of sex work, homelessness as a child and adult, and a history incarceration were associated with higher odds of experiencing a transphobic hate crime. Trans women who felt their gender identity questioned had lower odds of reporting a hate crime to the police compared to those did not feel questioned.

Conclusions

A high proportion of trans women experienced a transphobic hate crime, with significant socio-structural risk factors and racial differences by crime type. However, crimes were underreported to the police. Interventions that address structural factors, especially among trans women of color, can yield violence prevention benefits.

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Improved PrEP Awareness and Use among Trans Women in San Francisco, California

August 14, 2021, 12:00 am

≫ Next: A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care

≪ Previous: Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race

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Abstract

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system.

A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care

March 3, 2022, 12:00 am

≫ Next: In Their Own Words: How Trans Women Acquired HIV Infection

≪ Previous: Improved PrEP Awareness and Use among Trans Women in San Francisco, California

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Abstract

Background

To determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community.

Methods

Interviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman.

Results

Violence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016.

Conclusion

Our findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization.

In Their Own Words: How Trans Women Acquired HIV Infection

June 1, 2022, 12:00 am

≪ Previous: A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care

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Abstract

Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM) in epidemiologic studies and HIV surveillance data. Trans women enrolled in the 2019/2020 National HIV Behavioral Surveillance Study in San Francisco were asked an open-ended question about how they were infected with HIV. The most common responses were “Sex with a straight cisgender man partner when the respondent identified as a trans woman” (43.0%); “Sexual assault” (13.9%); “Injection drug use (IDU)” (10.1%); “IDU or sexual contact” (7.6%) and “Sex with a partner who injected drugs” (7.6%). Sex with a cisgender man partner prior to identifying as a trans women (MSM contact) was not mentioned by any respondent. HIV prevention strategies targeting MSM will fail to reach trans women and many of their cisgender men partners.