Sex work, gender transition, family rejection and depressive symptoms among transgender women in India.

Background: Transgender women in India face unique stressors associated with minority experiences, such as experiences of gender transition and participation in sex work. However, the relationship between sex work, transition and mental health outcomes is understudied in this population. Aims: This article aims to examine the association between gender transition status, sex work, family rejection and depressive symptoms among transgender women in India. Methods: Data comes from a cross-sectional epidemiological study with transgender women from three states of India; Karnataka, Maharashtra and Tamil Nadu (N = 1366). Multivariate regressions were used to examine the association between sex work status and gender transition and how gender transition, and sex work are associated with depressive symptoms. Results: 70% of the sample reported being in sex work and over 82% endorsed taking some form of gender transition service. Those who reported being in sex work were significantly more likely to have undergone breast augmentation, hormonal therapy and gender affirming surgery. Those who reported ever being married were less likely to report gender affirming surgery and were more likely to report hormonal therapy. Additionally, being in sex work, undergoing transition, leaving home because of sexual orientation, and being married were significantly associated with depressive symptoms. Discussion: Community-led organizations and other service agencies must incorporate intersectional experiences and identities, including sex work and gender transition, in their programs to further social and health justice for transgender women in India. Policy and programmatic implications are discussed. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1939220.

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.

Increasing Contraceptive Use Among Young Married Couples in Bihar, India: Evidence From a Decade of Implementation of the PRACHAR Project.

BACKGROUND: Evidence on effective behavior change programming for sexual and reproductive health among married youth aged 15-24 in developing countries is lacking. To address this gap, we examined monitoring, evaluation, and special study data from the Promoting Change in Reproductive Behavior of Adolescents (PRACHAR) Project, which was implemented between 2001 and 2012 in Bihar, India, over 3 phases using 2 different implementation models (NGO- and government-led). METHODS: We conducted a synthesis of evidence from multiple PRACHAR studies to identify key findings on intervention effectiveness, scalability, and sustained effects on behaviors. Data were triangulated from quantitative population-based quasi-experimental evaluations from each project phase; the project's performance monitoring database; and qualitative studies with beneficiaries. RESULTS: PRACHAR's original comprehensive NGO-led model, which included behavior change elements and multiple overlapping communication channels (including home visits and small-group meetings), increased contraceptive use among young married couples, and these outcomes were sustained 4-8 years after project interventions ended. Several program elements were critical to the effectiveness of PRACHAR, including use of a socioecological intervention model with emphasis on behavior change efforts; use of a gender-synchronized approach that engages both male and female partners; and intensity of interventions calibrated to different moments in the life cycle of adolescents and youth. While the hybrid government-NGO model of PRACHAR implementation reached greater scale than the original NGO-led model, comparison of results suggests trade-offs in effectiveness of interventions and sustained impacts. CONCLUSIONS: A decade of learning from the PRACHAR Project in Bihar, India, finds that comprehensive programming with gender-synchronized interventions tailored to specific life stages and aimed at different levels of the socioecological model can effectively increase contraceptive use among married young people in a conservative context. Shifting from a more intensive NGO-led model to less intensive government implementation enhances scalability but may have diminished impact on reach and long-lasting effectiveness.

A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening.

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2-year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever-screened and never-screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health-seeking behavior for gynecological and breast-related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.

The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India.

CONTEXT: Contraceptive use among young couples in India is low, and early childbearing and short birth intervals are common. The PRACHAR Project, an ongoing intervention in Bihar, seeks to increase contraceptive use for delaying and spacing births through communication interventions. METHODS: Random samples of married women younger than 25 with no more than one child were surveyed in 2002-2003, before PRACHAR was implemented (N=1,995), and in 2004, 21-27 months after implementation (N=2,080). Contraceptive demand and use, and related attitudes and knowledge, were assessed in the two surveys in both intervention areas and comparison areas. Logistic regression was used to assess the effect of the interventions on these indicators. RESULTS: Contraceptive use was very low (2-6%) at baseline in both comparison and intervention areas. Demand for contraception increased from 25% at baseline to 40% at follow-up in intervention areas, but remained virtually unchanged in comparison areas. At follow-up, contraceptive use had risen in both areas, but the adjusted odds of use in intervention areas were 3.8 times those in comparison areas. Women in intervention areas had elevated odds of knowing that fertility varies during the menstrual cycle, and of agreeing that early childbirth can be harmful and that contraceptive use is necessary and safe for delaying first births (odds ratios, 1.6-3.0). CONCLUSION: Culturally appropriate, community-based communication programs that target youth and those who influence their decisions can create demand for contraception among young couples and lead to increased contraceptive use.