Latent Constructs of Economic Marginality Associated with Sexual Behavior, Healthcare Access and HIV Outcomes Among Transgender and Nonbinary People in Three U.S. Cities.

Transgender and nonbinary people (TNB) in the U.S. experience high HIV prevalence and diverse economic hardships. Yet a comprehensive understanding of how multiple, simultaneously occurring hardships-termed economic marginality-are together associated with healthcare and HIV outcomes is needed. Leveraging survey data from a sample of 330 TNB people in three U.S. cities, we conducted an exploratory mixed-source principal component analysis of latent factors of economic experience, then estimated their associations with sexual behavior, access to healthcare, HIV status, and HIV testing frequency. Two factors emerged: a traditional socioeconomic factor related to income, education, and employment (SES), and one related to housing precarity and (lack of) assets (Precarity). Higher Precarity scores were associated with sexual behavior, cost-based healthcare avoidance, discrimination-based healthcare avoidance, and more frequent HIV testing. Findings highlight the importance of understanding profiles of economic marginalization among trans and nonbinary people and can inform efforts to address upstream, structural factors shaping healthcare access and HIV outcomes in this key population.

General self-efficacy as a mediator of the association between adverse childhood experiences and psychological distress in gender-minority individuals.

PURPOSE: To investigate the mediating role of general self-efficacy (i.e., belief in one's competence to cope with a broad range of stressful or challenging demands) in the relationship between adverse childhood experiences (ACEs) and psychological distress (i.e., symptoms of stress, anxiety and depression) in gender minority individuals, which include people with a gender identity that is not aligned with their sex assigned at birth. DESIGN AND METHODS: The study sample included gender minority participants who participated in Waves 4 and 5 of Project AFFIRM, a multi-site longitudinal study of gender minority health. ACEs, general self-efficacy, and psychological distress were measured using the Behavior Risk Factor Surveillance System ACE Module at Wave 4, the PROMIS General self-efficacy measure at Wave 4, and the Brief Symptoms Inventory Global Severity Index (GSI) at Wave 5, respectively. After adjustment for covariates, including age, race, sex assigned at birth, and income, multivariable linear regression analyses were conducted to assess each component of the proposed mediation model. Next, mediation analyses were used to determine whether general self-efficacy mediated the association between ACEs and psychological distress. FINDINGS: The sample for this study consisted of 166 gender minority adults with a mean age of 38.6 ± 12.2 years. Most were non-Hispanic White (46.4%) and female assigned at birth (59.6%). Mean ACEs score was 3.2 ± 2.1 (range 0-8), mean general self-efficacy score was 13.9 ± 3.6 (range 4-20), and mean raw-score GSI was 17.3 ± 13.7 (range 0-64). Participants who reported experiencing more ACEs had greater psychological distress (B 1.60; 95% CI = 0.66, 2.54) and lower general self-efficacy (B -0.41; 95% CI = -0.67, -0.15). In addition, lower general self-efficacy was associated with higher psychological distress (B -1.06; 95% CI = -1.61, -0.51). Bootstrap estimation of the indirect effect was significant (95% CI = 0.14, 0.90) and explained 27.1% (95% CI = 7.76, 69.76) of the total effect of ACEs on psychological distress in gender minority adults. CONCLUSIONS: Our findings suggest that general self-efficacy partially mediated the positive association between ACEs and psychological distress in gender minority adults. Interventions that aim to improve general self-efficacy may be beneficial in alleviating psychological distress in gender minority adults. CLINICAL RELEVANCE: Nurses can play an important role in reducing the health risks associated with ACEs by screening gender minority individuals using a trauma-informed approach to care and offering resources and referrals, as appropriate.

Prospective relationships between stigma, mental health, and resilience in a multi-city cohort of transgender and nonbinary individuals in the United States, 2016-2019.

PURPOSE: Gender-based stigma is a fundamental cause of mental health disparities among transgender and non-binary (TGNB) individuals, while resilience factors may be protective. We examined prospective relationships between gender-based enacted stigma, psychological distress, and resilience factors among TGNB individuals. METHODS: Between 2016 and 2017, we enrolled 330 TGNB individuals in three metropolitan areas in the U.S. in a prospective cohort study focused on gender identity development, risk, and resilience across the lifespan. Using multilevel regression, we examined prospective associations between enacted gender-based stigma and psychological distress (measured by the Global Severity Index/BSI-18), and examined transgender pride and social support as moderators, adjusting for age, sex assigned at birth, race/ethnicity, education, and income. RESULTS: Our sample was diverse in age (M = 34.4, range 16-87) and race/ethnicity (56.4% non-White). Over 2 years of follow-up, there was a decrease in reported gender-based stigma (b = - 0.61, p < 0.001) and transgender pride (b = - 0.14, p = 0.003), increase in social support (b = 0.21, p < 0.001), and no change in psychological distress. In adjusted analyses, gender-based stigma was positively associated with psychological distress (b = 1.10, p < 0.001) and social support was negatively associated with psychological distress (b = - 2.60, p < 0.001). Transgender pride moderated the relationship between stigma and psychological distress (p < 0.01), such that the association was stronger for lower levels of transgender pride. CONCLUSIONS: Our study provides longitudinal evidence for the deleterious role of gender-based stigma among TGNB individuals. Future interventions should consider fostering transgender pride and social support to promote mental health and mitigate negative effects of gender-based stigma.

Stigmatization, Resilience, and Mental Health Among a Diverse Community Sample of Transgender and Gender Nonbinary Individuals in the U.S.

Transgender and gender nonbinary (TGNB) individuals were recently designated a health disparity population by the U.S. National Institutes of Health. We examined the effect of gender-related discrimination and resilience factors on the mental health of a community sample diverse in gender identity, age, and race/ethnicity. We report on the baseline data of a longitudinal study of transgender identity development across the lifespan with 330 TGNB individuals recruited through venue-based recruitment in three major metropolitan areas in the U.S. Mean age of participants was 34.4 years (SD = 13.7). Structured interviews collected self-report data on sociodemographics, gender-related discrimination, mental health, and resilience. We used hierarchical regression to examine the association between gender-related discrimination and psychological distress (BSI-18) and tested the moderating effect of family support, transgender community connectedness, gender literacy, and transgender activism on this relationship. In adjusted analyses, gender-related discrimination was positively associated with psychological distress. Family support was negatively associated with psychological distress. Contrary to our expectations, gender literacy and transgender activism were positively associated with psychological distress, while no significant relationship was found for transgender community connectedness. Family support, transgender community connectedness, gender literacy, and transgender activism did not moderate the effect of gender-related discrimination on psychological distress. Future mental health interventions should consider leveraging family support among TGNB individuals. Longitudinal studies are needed to better understand the role of gender literacy and activism with respect to mental health and development of identity and resilience among TGNB people.

Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS.

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.

Trans adolescents' perceptions and experiences of their parents' supportive and rejecting behaviors.

Transgender (trans) adolescents consistently report higher rates of adverse mental health outcomes compared to their cisgender peers. Parental support is a recognized adolescent protective factor; however, little is known about the specific parental behaviors that trans adolescents perceive as most or least supportive. To address this gap, we analyzed data from qualitative interviews conducted with an ethnically diverse, urban-based sample of trans adolescents (N = 24; 16-20 years old) to describe (a) the spectrum of specific parental behaviors across 3 categories-rejecting, supportive, and mixed (i.e., simultaneous supportive and rejecting behaviors)-and (b) the perceived psychosocial consequences across these 3 categories of parental behaviors. Qualitative data were gathered through lifeline interviews (i.e., visual representations from birth to present) and photo elicitation (i.e., photographs representing parental support and/or rejection). Supportive behaviors included instances where parents made independent efforts to learn about trans issues or help their child obtain gender-affirming health care. Rejecting behaviors included instances when parents refused to use their child's name or pronouns or failed to show empathy when their child struggled with gender-identity-related challenges. Mixed behaviors included examples when parents expressed support of their child's gender identity, but not of their sexual orientation (or vice versa). Overall, participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing. These findings expand upon descriptions of parental support and rejection within the trans adolescent literature and can help practitioners target specific behaviors for interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Mental Health Promotion for Gender Minority Adolescents.

The current study uses an ecological model of biopsychosocial vulnerability to guide the description of risk and protective factors for the mental health of gender minority (i.e., transgender and gender non-conforming) adolescents at the individual, family, community, and societal levels. Minority stress is the vulnerability of youth who are lesbian, gay, bisexual, and transgender (LGBT) to adverse mental health outcomes due to stigma. In addition, unlike cisgender (non-transgender) LGB individuals, gender minorities may experience internal stress related to gender dysphoria. Gender dysphoria may lead to interaction with health care providers who may not be educated in the care of gender minority youth. The ecological model is an organizing framework for understanding domains of health risks that affect such youth to assist nurses in intervening to promote the health of gender minority adolescents. Specific attention is paid to the potential contributions of psychiatric-mental health nurses to the care of gender minority adolescents. [Journal of Psychosocial Nursing and Mental Health Services, 56(12), 22-30.].

Demographic Characteristics and Health Status of Transgender Adults in Select US Regions: Behavioral Risk Factor Surveillance System, 2014.

OBJECTIVES: To describe the health status of the transgender population in the United States. METHODS: We used 2014 Behavioral Risk Factor Surveillance System data that comprised a probability sample from 19 US states and Guam (n = 151 456). RESULTS: Bivariate analyses showed that, in comparison with cisgender individuals, transgender individuals had a higher prevalence of poor general health (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2, 2.4), more days per month of poor physical (b = 2.43; 95% CI = 0.61, 4.24; P < .01) and mental (b = 1.74; 95% CI = 0.28, 3.19; P = .02) health, and a higher prevalence of myocardial infarction (OR = 1.7; 95% CI = 1.1, 2.5). In addition, more transgender than cisgender people lacked health care coverage (OR = 1.8; 95% CI = 1.2, 2.7) and a health care provider (OR = 1.5; 95% CI = 1.0, 2.1), and they were less likely to have visited a dentist in the preceding year (OR = 0.7; 95% CI = 0.5, 1.0). However, transgender individuals did not differ from cisgender individuals with respect to prevalence of chronic diseases, cancers, or depressive disorders or in terms of health behaviors such as smoking, binge drinking, and always wearing a seatbelt. CONCLUSIONS: Our findings highlight areas of unmet needs in the transgender population.

Demographic Characteristics, Components of Sexuality and Gender, and Minority Stress and Their Associations to Excessive Alcohol, Cannabis, and Illicit (Noncannabis) Drug Use Among a Large Sample of Transgender People in the United States.

The current study examined demographics, sexual orientation, gender characteristics, and gender minority stress and their association to excessive alcohol, cannabis, and illicit (noncannabis) drug use among 1210 transgender adults living in the United States. The authors conducted a secondary analysis of data that included 680 transgender women (M age = 32.63, SD age = 12.29) and 530 transgender men (M age = 26.14, SD age = 7.42). A modified version of the Risk Behavioral Assessment quantified participants' alcohol, cannabis, and illicit drug use in the past 3 months. Overall, 21.5% of participants reported excessive alcohol use; no significant differences were found on the rates of excessive alcohol use between transgender women and men. Cannabis use among our sample was 24.4%; trangender men reported significantly higher rates of cannabis use compared to transgender women. Illicit drug (noncannabis) use among our sample was 11.6%; transgender men also reported significantly higher rates of illicit drug use compared to transgender women. Multivariate analyses suggested that gender dysphoria was significantly associated with: excessive alcohol use for transgender women, cannabis use among both transgender women and men, and illicit (noncannabis) drug use among transgender women. A nonheterosexual orientation was associated with increased odds of cannabis use among transgender women and men; a nonheterosexual orientation was associated with greater odds of illicit substance use among transgender men but not among transgender women. Gender minority stressors were independently associated with excessive alcohol use among transgender men and cannabis use among transgender women. The authors suggest that minority stress may only partially account for substance use among transgender people. Consequently, the authors suggest that in addition to minority stress, other biopsychosocial mechanisms should continue to be examined to identify pathways that may lead to the development of effective substance use prevention efforts and treatment programs.

Recommendations for internet-based qualitative health research with hard-to-reach populations.

Researchers new to online qualitative health research frequently have questions about how to transfer knowledge of offline data collection to an online environment. In this article, we present best-practice guidelines derived from the literature and our experience to help researchers determine if an online qualitative study design is appropriate for their research project and, if so, when to begin data collection with a hard-to-reach population. Researchers should reflect on administrative, population, and data collection considerations when deciding between online and offline data collection. Decisions must be made regarding whether to conduct interviews or focus groups, to collect data using asynchronous or synchronous methods, and to use only text or to incorporate visual media. Researchers should also reflect on human subjects, recruitment, research instrumentation, additional data collection, and public relations considerations when writing protocols to guide the research team's response to various situations. Our recommendations direct researchers' reflection on these considerations.

Day-to-day associations of intersectional minority stressors with sleep health in sexual and gender minority people of color.

OBJECTIVE: To determine the day-to-day associations between minority stressors (i.e., anticipated and experienced discrimination) and sleep health outcomes (i.e., total sleep time (TST), sleep disturbances, and sleep-related impairment) among sexual and gender minority (SGM) people of color. METHOD: An online sample of SGM people of color living in the United States participated in a 30-day daily diary study. Daily anticipated and experienced discrimination as well as subjective sleep outcomes were assessed via electronic diaries using validated measures. Wrist-worn actigraphy was used to objectively assess TST. Multilevel linear models (MLMs) were used to estimate the independent associations of daily intersectional minority stressors with subsequent sleep outcomes, adjusted for demographic factors and lifetime discrimination. RESULTS: The sample included 43 SGM people of color with a mean age of 27.0 years (± 7.7) of which 84% were Latinx, 47% were multiracial, and 37% were bisexual. Results of MLMs indicated that greater report of daily experienced discrimination was positively associated with same-night sleep disturbances, B (SE) = 0.45 (0.10), p < .001. Daily anticipated discrimination was positively associated with sleep-related impairment on the following day, B (SE) = 0.77 (0.17), p < .001. However, daily anticipated and experienced discrimination were not associated with same-night TST. CONCLUSIONS: Findings highlight the importance of considering the differential effects of daily intersectional minority stressors on the sleep health of SGM people of color. Further research is needed to identify factors driving the link between daily minority stressors and sleep outcomes to inform sleep health interventions tailored to this population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Stigma, mental health, and resilience in an online sample of the US transgender population.

OBJECTIVES: We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population. METHODS: In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations. RESULTS: Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity. CONCLUSIONS: Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City.

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

A qualitative study of alcohol use disorder psychotherapies for transgender and nonbinary individuals: Opportunities for cultural adaptation.

BACKGROUND: Transgender and nonbinary (TGNB) populations experience high rates of hazardous drinking (HD) and alcohol use disorder (AUD) as well as unique treatment barriers. This is due, in-part, to discrimination and stigma within and outside of the healthcare system. Cultural adaptation of clinical interventions can improve outcomes for marginalized populations, but no such adapted interventions exist for AUD among TGNB individuals. This study sought to understand how TGNB individuals perceive currently available AUD psychotherapies and to generate knowledge about potential areas for cultural adaptation. METHODS: As part of a qualitative study of HD among TGNB individuals (N=27), participants were asked to imagine that they were clients in psychotherapy vignettes corresponding to cognitive behavioral therapy, motivational enhancement therapy, and twelve step facilitation. Interviews were audio-recorded and professionally transcribed. A coding team used an iterative codebook to guide coding. Categories emerged from this process that reflected participants' perceptions and allowed for the identification of potential cultural-adaptation targets. RESULTS: Across all three psychotherapies, participants wanted therapists to explicitly discuss gender identity and culturally salient HD risk factors for TGNB individuals (e.g., discrimination, stigma, gender dysphoria). There were also modality-specific recommendations to incorporate principles of trauma-informed care into cognitive behavioral therapy, avoid motivational enhancement therapy exercises that oversimplify decision-making, and recognize that the twelve-step-facilitation concept of "powerlessness" may conflict with how many TGNB people see themselves. CONCLUSIONS: These findings highlight areas for cultural adaptation that can be evaluated in future intervention trials in an effort to improve psychotherapy acceptability and efficacy for TGNB individuals.

Prevalence of substance use and mental health problems among transgender and cisgender U.S. adults: Results from a national probability sample.

Transgender individuals experience numerous health disparities relative to cisgender individuals. However, most transgender-health studies have focused on convenience samples with limited generalizability. This study utilized data from the 2016-2018 TransPop Study, the first national probability sample of transgender adults (n=274) with a cisgender comparison sample (n=1162). Using multivariable logistic regression, adjusted for demographics, we compared the prevalence of hazardous drinking, problematic drug use, serious psychological distress, suicidality, and non-suicidal self-injury between transgender and cisgender individuals and among transgender men (n=78), transgender women (n=120), and transgender nonbinary individuals (n=76). Among transgender individuals, 28.2% (95%CI 21.2-35.2) and 31.2% (95%CI 23.8-38.7) reported hazardous drinking and problematic drug use, respectively; 44.4% (95% CI 35.8-53.0) reported recent suicidal ideation, 6.9% (95% CI 2.3-11.5) reported a recent suicide attempt, and 21.4% (95% CI 14.5%-28.4%) reported recent non-suicidal self-injury. In their lifetime, 81.3% (95%CI 75.1-87.5) of transgender respondents had suicidal ideation, 42.0% (95%CI 34.2-49.8) had attempted suicide, and 56.0% (95% CI 48.2-63.8) reported non-suicidal self-injury. Most (81.5%; 95%CI 75.5-87.5) had utilized formal mental health care and 25.5% (95%CI 18.5-32.4) had sought informal mental health support. There were no differences in alcohol or drug-use outcomes between transgender and cisgender adults. Compared to cisgender adults, transgender adults had higher odds of serious psychological distress (aOR=3.1; 95%CI 1.7-5.7), suicidal ideation (recent: aOR=5.1, 95%CI 2.7-9.6); lifetime: aOR=6.7, 95%CI 3.8-11.7), lifetime suicide attempts (aOR=4.4, 95%CI 2.4-8.0), and non-suicidal self-injury (recent: aOR=13.0, 95%CI 4.8-35.1); lifetime: aOR=7.6, 95%CI 4.1-14.3). Transgender nonbinary adults had the highest odds for all outcomes, including substance use outcomes. Findings from these national probability samples support those of earlier convenience-sample studies showing mental health disparities among transgender adults relative to cisgender adults, with nonbinary individuals at highest risk. These findings also highlight variations in risk across sub-groups of transgender individuals.

Conducting Internet Research With the Transgender Population: Reaching Broad Samples and Collecting Valid Data.

Health research on transgender people has been hampered by the challenges inherent in studying a hard-to-reach, relatively small, and geographically dispersed population. The Internet has the potential to facilitate access to transgender samples large enough to permit examination of the diversity and syndemic health disparities found among this population. In this article, we describe the experiences of a team of investigators using the Internet to study HIV risk behaviors of transgender people in the United States. We developed an online instrument, recruited participants exclusively via websites frequented by members of the target population, and collected data using online quantitative survey and qualitative synchronous and asynchronous interview methods. Our experiences indicate that the Internet environment presents the investigator with some unique challenges and that commonly expressed criticisms about Internet research (e.g., lack of generalizable samples, invalid study participants, and multiple participation by the same subject) can be overcome with careful method design, usability testing, and pilot testing. The importance of both usability and pilot testing are described with respect to participant engagement and retention and the quality of data obtained online.

Examining the role of problematic drug use in the relationship between discrimination and sleep disturbance in transgender and nonbinary individuals.

OBJECTIVE: Transgender and nonbinary (TGNB) individuals are a health disparity population at high risk for sleep disturbance (e.g., insomnia). Recent evidence suggests minority stress (e.g., discrimination) is associated with sleep disturbance in TGNB adults. However, investigators have yet to identify factors that might explain this relationship. In this study, we investigated the role of problematic drug use (PDU) in the relationship between discrimination and sleep disturbance in TGNB individuals. METHODS: The study sample included 194 TGNB participants from Wave 5 (2021) of Project AFFIRM, a multi-site longitudinal study of transgender health. Discrimination, PDU, and sleep disturbance were measured using the Everyday Discrimination Scale, Drug Use Disorders Identification Test (DUDIT), and PROMIS Sleep Disturbance measures, respectively. Individuals were classified as having PDU using established DUDIT criteria that were applied based on sex assigned at birth. Regression analyses were used to estimate the associations of study variables, and subsequently, mediation analysis was used to determine whether PDU partially mediated the association between discrimination and sleep disturbance. RESULTS: Nearly half of participants reported PDU, of which 83.2% reported cannabis use. Higher levels of discrimination were associated with worse self-reported sleep disturbance scores. Additionally, participants with greater discrimination were more likely to have PDU. Surprisingly, participants with PDU had lower sleep disturbance scores. CONCLUSIONS: Our cross-sectional findings suggest that PDU partially suppressed the association between discrimination and sleep disturbance in TGNB people. Efforts to address PDU in TGNB adults may consider assessing sleep disturbance as a motivating factor for drug use and the potential role of discrimination in perpetuating PDU.

Past Experiences and Anticipated Futures in the Lives of Transgender and Nonbinary People.

Transgender and nonbinary people's life experiences are highly heterogenous and shaped by broader structural and cultural forces. We analyze experiences identified on lifeline interviews from 87 transgender and nonbinary adults in Atlanta, New York City, and San Francisco. We find that the type, timing, and relative importance of these experiences varied across categories. For example, experiences related to "Rejection and violence" were more often identified in childhood and in the past, whereas experiences related to "Gender-affirming medical interventions" were more often in adulthood and anticipated futures. Experiences related to "Community involvement," "Extracurriculars," "Gender exploration and revelation," and "Gender-affirming medical interventions" were labeled by respondents as relatively more important compared to other experiences, whereas experiences related to "Family of origin relationships," "Place of residence," "Rejection and violence," and "Sexuality" less important. These experiences were patterned according to the respondents' gender, birth cohort, race/ethnicity, and geographic location. In analyzing these lifeline data, we advance theoretical understandings of the salience of a variety of key experiences for transgender and nonbinary people at different points in the life course. Our life course approach provides empirical analyses of intra-individual processes over time for transgender and nonbinary people and provides insight into the usefulness of a lifeline method for life course studies more generally as it draws attention to within-person assessments of the distribution and importance of events over the course of a lifetime.