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BACKGROUND: Data on the epidemiology of sexually transmitted infections (STIs) among transgender women (TGW) with and without human immunodeficiency virus (HIV) are limited. METHODS: We analyzed baseline data collected from a cohort of adult TGW across 6 eastern and southern US cities between March 2018 and August 2020 (n = 1018). Participants completed oral HIV screening, provided self-collected rectal and urogenital specimens for chlamydia and gonorrhea testing, and provided sera specimens for syphilis testing. We assessed associations with ≥1 prevalent bacterial STI using modified Poisson regression. RESULTS: Bacterial STI prevalence was high and differed by HIV status: 32% among TGW with HIV and 11% among those without HIV (demographic-adjusted prevalence ratio = 1.91; 95% confidence interval = 1.39-2.62). Among TGW without HIV, bacterial STI prevalence differed by geographic region, race and ethnicity, and gender identity, and was positively associated with reporting >1 sexual partner, hazardous alcohol use, homelessness, having safety concerns regarding transit to health care, and no prior receipt of gender-affirming health services. Among TGW with HIV, older age was inversely associated with bacterial STI. CONCLUSIONS: TGW had a high prevalence of bacterial STIs. The prevalence and correlates of bacterial STI differed by HIV status, highlighting the unique needs and risks of TGW with and without HIV. Tailored interventions may reduce sexual health-related inequities.
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Infecções por HIV , Infecções Sexualmente Transmissíveis , Pessoas Transgênero , Humanos , Feminino , Adulto , Pessoas Transgênero/estatística & dados numéricos , Prevalência , Infecções por HIV/epidemiologia , Infecções Sexualmente Transmissíveis/epidemiologia , Adulto Jovem , Estados Unidos/epidemiologia , Adolescente , Pessoa de Meia-Idade , Gonorreia/epidemiologia , Masculino , Parceiros Sexuais , Sudeste dos Estados Unidos/epidemiologia , Infecções por Chlamydia/epidemiologia , Sífilis/epidemiologia , Comportamento Sexual , Fatores de RiscoRESUMO
Sexual and gender minority (SGM) adults experience poor health outcomes, in part due to frequent avoidance of necessary health care. Little is known, however, about factors contributing to patterns of health care utilization in this population. Using national data from the All of Us Research Program, this study evaluated the prevalence of care avoidance due to patient-clinician identity discordance (PCID) and its association with health care discrimination among SGM adults. Sexual minority (20.0% vs 9.4%; adjusted rate ratio [aRR] = 1.58; 95% CI, 1.49-1.67, P <0.001) and gender minority adults (34.4% vs 10.3%; aRR = 2.00; 95% CI, 1.79-2.21, P <0.001) were significantly more likely than their non-SGM counterparts to report care avoidance due to PCID. Exposure to health care discrimination was also more prevalent in this population and was dose-dependently associated with significantly higher rates of PCID-based care avoidance. Study findings highlight the importance of diversifying the health care workforce, expanding SGM-related clinical training, and preventing health care discrimination against SGM patients.
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Minorias Sexuais e de Gênero , Humanos , Minorias Sexuais e de Gênero/estatística & dados numéricos , Minorias Sexuais e de Gênero/psicologia , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Estados Unidos , Relações Médico-Paciente , Adulto Jovem , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Adolescente , IdosoRESUMO
Globally, transgender women (TW) face a high burden of the HIV epidemic. In Peru, HIV prevalence among TW rises at age 25, indicating a need to understand HIV vulnerability as adolescents reach adulthood. The life course of TW is often marked by abuse, discrimination and poverty fueled by transphobic stigma. Approaches to the HIV epidemic among TW and adolescents emphasize problem behaviors such as unprotected sex and substance. However, there has been a call for HIV research and interventions to understand and leverage community strengths. This qualitative study utilized a transgender-oriented, strength-based, intersectional and feminist approach to understand the strengths and protective health behaviors among 17 transgender adolescents and young women (TAYW) age 16-24 in Lima, Peru. Most participants re-located to Lima from the Amazon due to familial rejection, and engaged in obligatory sex work. TAYW demonstrated self-knowledge, motivation for education, efforts to secure employment, strong community networks, legal advocacy, avoiding problem substance use, HIV knowledge and condom use. However, strengths were impeded by multi-level barriers such as familial physical abuse, educational discrimination, and sexual assault which led to increased HIV vulnerability. We created a conceptual model of the "cycle" of HIV to describe the limits of personal responsibility within a vulnerable community denied access to family, education, employment and human rights. We recommend researchers, clinicians and public health workers follow the lead of TAYW at the frontlines of the HIV epidemic, and support beloved communities and enabling environments which may permit protective behaviors to mitigate HIV vulnerability.
RESUMEN: A nivel mundial, las mujeres transgénero (MT) enfrentan una alta carga de la epidemia del VIH. En Perú, la prevalencia del VIH entre las MT aumenta a los 25 años, lo que indica la necesidad de comprender la vulnerabilidad al VIH a medida que las adolescentes llegan a la edad adulta. El curso de vida de las MT suele estar marcado por el abuso, la discriminación y la pobreza por culpa del estigma transfóbico. Los enfoques sobre la epidemia del VIH entre las MT y los adolescentes enfatizan conductas problemáticas como el sexo sin protección o el uso de sustancias. Sin embargo, existe un llamado a realizar investigaciones e intervenciones sobre el VIH para comprender y aprovechar las fortalezas de la comunidad. Este estudio cualitativo utilizó un enfoque feminista, interseccional, basado en fortalezas y orientado a las personas transgénero para comprender las fortalezas y los comportamientos protectores de la salud entre 17 adolescentes y mujeres jóvenes transgénero de 16 a 24 años en Lima, Perú. La mayoría de las participantes migraron a Lima desde la Amazonía debido al rechazo familiar y se dedicaron al trabajo sexual obligatorio. Las adolescentes y mujeres jóvenes transgénero demostraron autoconocimiento, motivación para la educación, esfuerzos para conseguir empleo, redes comunitarias sólidas, defensa legal, evitar el uso problemático de sustancias, conocimiento sobre el VIH y uso de condones. Sin embargo, las fortalezas se vieron obstaculizadas por barreras de múltiples niveles, como el abuso físico familiar, la discriminación educativa y la agresión sexual, que llevaron a una mayor vulnerabilidad al VIH. Desarrollamos un modelo conceptual del "ciclo" del VIH para describir los límites de la responsabilidad personal dentro de una comunidad vulnerable a la que se le niega el acceso a la familia, la educación, el empleo y los derechos humanos. Recomendamos que los investigadores, médicos y trabajadores de la salud pública sigan el ejemplo de adolescentes y mujeres jóvenes transgénero en la primera línea de la epidemia del VIH y apoyen a comunidades queridas y entornos propicios que puedan permitir conductas protectoras para mitigar la vulnerabilidad al VIH.
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INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) for HIV-1 infection is over 99% effective in protecting against HIV acquisition when used consistently and appropriately. However, PrEP uptake and persistent use remains suboptimal, with a substantial gap in utilization among key populations who could most benefit from PrEP. In Latin America specifically, there is poor understanding of barriers to PrEP uptake and persistence among transgender (trans) women. METHODS: In April-May 2018, we conducted qualitative interviews lasting 25-45 min as part of an end-of-project evaluation of TransPrEP, a pilot RCT that examined the impact of a social network-based peer support intervention on PrEP adherence among trans women in Lima, Peru. Participants in the qualitative evaluation, all adult trans women, included individuals who either (1) screened eligible to participate in the TransPrEP pilot, but opted not to enroll (n = 8), (2) enrolled, but later withdrew (n = 6), (3) were still actively enrolled at the time of interview and/or successfully completed the study (n = 16), or (4) were study staff (n = 4). Interviews were audio recorded and transcribed verbatim. Codebook development followed an immersion/crystallization approach, and coding was completed using Dedoose. RESULTS: Evaluation participants had a mean age of 28.2 years (range 19-47). When describing experiences taking PrEP, participant narratives highlighted side effects that spanned three domains: physical side effects, such as prolonged symptoms of gastrointestinal distress or somnolence; economic challenges, including lost income due to inability to work; and social concerns, including interpersonal conflicts due to HIV-related stigma. Participants described PrEP use within a broader context of social and economic marginalization, with a focus on daily survival, and how PrEP side effects negatively contributed to these stressors. Persistence was, in some cases, supported through the intervention's educational workshops. CONCLUSION: This research highlights the ways that physical, economic, and social side effects of PrEP can impact acceptability and persistence among trans women in Peru, amplifying and layering onto existing stressors including economic precarity. Understanding the unique experiences of trans women taking PrEP is crucial to informing tailored interventions to improve uptake and persistence.
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Infecções por HIV , Profilaxia Pré-Exposição , Pesquisa Qualitativa , Pessoas Transgênero , Humanos , Peru , Feminino , Pessoas Transgênero/psicologia , Pessoas Transgênero/estatística & dados numéricos , Adulto , Infecções por HIV/prevenção & controle , Masculino , Adesão à Medicação/estatística & dados numéricos , Adesão à Medicação/psicologia , Projetos Piloto , Adulto Jovem , Fármacos Anti-HIV/uso terapêutico , Entrevistas como Assunto , Fatores Socioeconômicos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants. METHODS: Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots. RESULTS: In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color. CONCLUSIONS: The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.
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Pessoas Transgênero , Adulto , Humanos , Feminino , Estados Unidos , Estudos Transversais , Etnicidade , Análise Multinível , PolíticasRESUMO
BACKGROUND: Transgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States. METHODS: This study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status. RESULTS: Higher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. CONCLUSIONS: Gender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.
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Infecções por HIV , Resiliência Psicológica , Minorias Sexuais e de Gênero , Pessoas Transgênero , Adulto , Humanos , Estados Unidos/epidemiologia , Feminino , Estudos Transversais , Infecções por HIV/epidemiologia , Acessibilidade aos Serviços de Saúde , Identidade de GêneroRESUMO
PURPOSE: Transgender and gender diverse (TGD) adults are disproportionately affected by suicide. Social support and connection to the broader TGD community may help lower TGD adults' odds of having a suicide attempt (SA). The current study examined whether baseline levels of social support and community connectedness were associated with TGD adult's prospective odds of having a SA over 12 months of follow-up. METHODS: Longitudinal data for the current study came from a patient cohort of TGD adults enrolled in the LEGACY Project. Descriptive statistics and an attrition analysis were used to examine characteristics of the cohort and missingness over time. Logistic generalized estimating equation models were used to examine factors associated with patients' odds of having a past 6-month SA at 6- or 12-month follow-up. RESULTS: During the 12-month follow-up period, a total of 26 patients (3.1%; N = 830) reported having a SA. The 6-month incidence of SAs was approximately 2% at both 6- and 12-months of follow-up (6 months: N = 830; 12 months: N = 495). Baseline factors associated with increased odds of a future SA included gender identity (transfeminine vs. transmasculine: adjusted odds ratio [aOR] = 3.73, 95% confidence interval [CI] = 1.26-11.08; nonbinary vs. transmasculine: aOR = 3.09, 95% CI = 1.03-9.21), having a prior SA (aOR = 6.44, 95% CI = 2.63-15.79), and having moderate vs. high perceived social support (aOR = 4.25, 95% CI = 1.65-10.90). CONCLUSION: Lower levels of social support are associated with risk for future suicide attempts among TGD adults. Findings may inform screening practices for future suicide risk and the development of interventions to improve mental health outcomes for TGD adults.
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Apoio Social , Tentativa de Suicídio , Pessoas Transgênero , Humanos , Masculino , Tentativa de Suicídio/estatística & dados numéricos , Tentativa de Suicídio/psicologia , Feminino , Pessoas Transgênero/psicologia , Pessoas Transgênero/estatística & dados numéricos , Adulto , Pessoa de Meia-Idade , Estudos Longitudinais , Fatores de Risco , Estudos Prospectivos , Adulto JovemRESUMO
INTRODUCTION: Existing literature suggests that transgender women (TW) may be at high risk for adverse mental health due to stress attributed to combined experiences of stigma and complex social and structural vulnerabilities. Little research has examined how these co-occurring experiences relate to mental health. We aimed to test a theoretically driven conceptual model of relationships between stigma, social and structural vulnerabilities, and mental health to inform future intervention tailoring. DESIGN/METHODS: Partial least square path modeling followed by response-based unit segmentation was used to identify homogenous clusters in a diverse community sample of United States (US)-based TW (N = 1418; 46.2% White non-Hispanic). This approach examined associations between latent constructs of stigma (polyvictimization and discrimination), social and structural vulnerabilities (housing and food insecurity, unemployment, sex work, social support, and substance use), and mental health (post-traumatic stress and psychological distress). RESULTS: The final conceptual model defined the structural relationship between the variables of interest within stigma, vulnerability, and mental health. Six clusters were identified within this structural framework which suggests that racism, ethnicism, and geography may be related to mental health inequities among TW. CONCLUSION: Our findings around the impact of racism, ethnicism, and geography reflect the existing literature, which unfortunately shows us that little change has occurred in the last decade for TW of color in the Southern US; however, the strength of our evidence (related to sampling structure and sample size) and type of analyses (accounting for co-occurring predictors of health, i.e., stigma and complex vulnerabilities, reflecting that of real-world patients) is a novel and necessary addition to the literature. Findings suggest that health interventions designed to offset the negative effects of stigma must include anti-racist approaches with components to reduce or eliminate barriers to resources that contribute to social and structural vulnerabilities among TW. Herein we provide detailed recommendations to guide primary, secondary, and tertiary prevention efforts. CLINICAL RELEVANCE: This study demonstrated the importance of considering stigma and complex social and structural vulnerabilities during clinical care and design of mental health interventions for transgender women who are experiencing post-traumatic stress disorder and psychological distress. Specifically, interventions should take an anti-racist approach and would benefit from incorporating social support-building activities.
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Transtornos de Estresse Pós-Traumáticos , Pessoas Transgênero , Humanos , Feminino , Estados Unidos , Saúde Mental , Estigma Social , Pessoas Transgênero/psicologia , Análise dos Mínimos QuadradosRESUMO
OBJECTIVES: Gender-affirming hormonal therapies (GAHT) and HIV increase cardiovascular risk for transgender women (TW), yet there is a paucity of data quantifying cardiometabolic changes following GAHT initiation, particularly among TW with HIV. METHODS: The Féminas study enrolled TW from October 2016 to March 2017 in Lima, Peru. Participants reported sexual activity that was high risk for HIV acquisition or transmission. All were tested for HIV/ sexually transmitted infection and were given access to GAHT (oestradiol valerate and spironolactone), HIV pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) for 12 months. Biomarker measurement was done on stored serum, whereas fasting glucose and lipids were measured in real time. RESULTS: In all, 170 TW (32 with HIV, 138 without HIV) had median age 27 years and 70% prior GAHT use. At baseline, PCSK9, sCD14, sCD163, IL-6, sTNFRI/II, CRP and EN-RAGE levels were significantly higher in TW with HIV than in TW without HIV. High-density lipoprotein and total cholesterol were lower and insulin and glucose parameters were similar. All TW with HIV started ART, but only five achieved virological suppression at any time. No TW without HIV initiated PrEP. Over 6 months, all participants initiated GAHT and had worsening insulin, glucose and HOMA-IR. Large d-dimer decreases also occurred. Similar changes occurred in TW with and without HIV. CONCLUSIONS: In this unique cohort of TW, GAHT decreased d-dimer but worsened insulin sensitivity. Because PrEP uptake and ART adherence were very low, observed effects are primarily attributed to GAHT use. Further study is needed to better understand cardiometabolic changes in TW by HIV serostatus.
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Doenças Cardiovasculares , Infecções por HIV , Resistência à Insulina , Insulinas , Pessoas Transgênero , Humanos , Feminino , Adulto , Pró-Proteína Convertase 9 , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Estradiol/uso terapêutico , Glucose , Insulinas/uso terapêuticoRESUMO
BACKGROUND: Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses. OBJECTIVE: To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults. DESIGN: LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY. PARTICIPANTS: Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data. MAIN MEASURES: GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years. KEY RESULTS: The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up. CONCLUSIONS: GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.
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Objectives. To examine whether, and if so how, US national and state survey response rates changed after the onset of the COVID-19 pandemic. Methods. We compared the change in response rates between 2020 and 2019 of 6 (3 social and economic, 3 health focused) major US national surveys (2 with state response rates). Results. All the ongoing surveys except 1 reported relative decreases (â¼29%) in response rates. For example, the household response rate to the US Census American Community Survey decreased from 86.0% in 2019 to 71.2% in 2020, and the response rate of the US National Health Interview Survey decreased from 60.0% to 42.7% from the first to the second quarter of 2020. For all surveys, the greatest decreases in response rates occurred among persons with lower income and lower education. Conclusions. Socially patterned decreases in response rates pose serious challenges and must be addressed explicitly in all studies relying on data obtained since the onset of the pandemic. Public Health Implications. Artifactual reduction of estimates of the magnitude of health inequities attributable to differential response rates could adversely affect efforts to reduce these inequities. (Am J Public Health. 2023;113(6):667-670. https://doi.org/10.2105/AJPH.2023.307267).
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COVID-19 , Saúde da População , Humanos , COVID-19/epidemiologia , Pandemias , Inquéritos e Questionários , Desigualdades de SaúdeRESUMO
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.
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Síndrome da Imunodeficiência Adquirida , Infecções por HIV , Pessoas Transgênero , Transexualidade , Masculino , Humanos , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Estudos Transversais , Transexualidade/epidemiologiaRESUMO
BACKGROUND: Sexual orientation refers to a person's enduring emotional, romantic, or sexual attractions to other people. Sexual orientation measures do not typically consider desires for, or sexual behavior with, transgender people. We describe measures inclusive of transgender people and characterize sexual orientation identity, behavior, and attraction in a representative sample of the U.S. transgender population. METHODS: Between April 2016-December 2018, a U.S. national probability sample of transgender (n = 274) and cisgender (n = 1,162) adults were invited to complete a self-administered web or mailed paper survey. We assessed sexual identity with updated response options inclusive of recent identity terms (e.g., queer), and revised sexual behavior and attraction measures that included transgender people. Multiple response options were allowed for sexual behavior and attraction. Weighted descriptive statistics and sexual orientation differences by gender identity groups were estimated using age-adjusted comparisons. RESULTS: Compared to the cisgender population, the transgender population was more likely to identify as a sexual minority and have heterogeneity in sexual orientation, behavior, and attraction. In the transgender population, the most frequently endorsed sexual orientation identities were "bisexual" (18.9%), "queer" (18.1%), and "straight" (17.6%). Sexually active transgender respondents reported diverse partners in the prior 5 years: 52.6% cisgender women (CW), 42.7% cisgender men (CM), 16.9% transgender women (TW), and 19.5% transgender men (TM); 27.7% did not have sex in the past 5 years. Overall, 73.6% were "somewhat"/ "very" attracted to CW, 58.3% CM, 56.8% TW, 52.4% TM, 59.9% genderqueer/nonbinary-females-at-birth, 51.9% genderqueer/nonbinary-males-at-birth. Sexual orientation identity, behavior, and attraction significantly differed by gender identity for TW, TM, and nonbinary participants (all p < 0.05). CONCLUSIONS: Inclusive measures of sexual orientation captured diverse sexual identities, partner genders, and desires. Future research is needed to cognitively test and validate these measures, especially with cisgender respondents, and to assess the relation of sexual orientation and health for transgender people.
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Minorias Sexuais e de Gênero , Pessoas Transgênero , Feminino , Adulto , Humanos , Masculino , Identidade de Gênero , Comportamento Sexual , BissexualidadeRESUMO
BACKGROUND: Migration is recognized as a key determinant of health. Yet, limited research addresses the arc of intranational migration and, even less, the experiences of transgender (trans) adolescents and women migrants and the associated health vulnerabilities. Using intersectional stigma as a theoretical frame, this study seeks to better understand the sexual health vulnerabilities and needs of trans women migrants in Peru. METHODS: Between October and November 2016, in-depth interviews (n = 14) and two focus groups (n = 20) were conducted in Spanish with trans women in three Peruvian cities. To explore pre- and during migration experiences, focus groups were conducted in Pucallpa and Iquitos, key cities in the Amazon where trajectories often originate. To assess during migration and post-migration experiences, we conducted interviews in Pucallpa, Iquitos, and Lima to better understand processes of relocation. Audio files were transcribed verbatim and analysed via an immersion crystallization approach, an inductive and iterative process, using Dedoose (v.6.1.18). RESULTS: Participants described migration as an arc and, thus, results are presented in three phases: pre-migration; during migration; and post-migration. Intersectional stigma was identified as a transversal theme throughout the three stages of migration. The pre-migration stage was characterized by poverty, transphobia, and violence frequently motivating the decision to migrate to a larger city. Exploitation was also described as pervasive during migration and in relocation. Many participants spoke of their introduction to sex work during migration, as key to economic earning and associated violence (police, clients). CONCLUSION: Findings advance understandings of intranational migration and forced displacement as key determinants of trans women's health. Dimensions of violence at the intersection of classism and cisgenderism render trans women highly vulnerable at every step of their migratory journeys. Experiences of intranational mobility and relocation were described as uniquely tied to age, intersectional transphobic stigma, engagement in sex work, and multiple forms of violence, which impact and can magnify sexual health vulnerabilities for transgender women in Peru who migrated intranationally.
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Infecções por HIV , Pessoas Transgênero , Humanos , Feminino , Adolescente , Peru , Estigma Social , Trabalho Sexual , ViolênciaRESUMO
Lesbian, gay, bisexual, transgender/nonbinary, and queer (LGBTQ +) adolescents experience considerable disparities in dating violence and sexual assault victimization relative to heterosexual and cisgender peers. These disparities may be driven in part by the disruptive effects of heterosexism and cissexism on school-based and family relationships. To quantify the potential roles of these processes and identify priorities for prevention efforts, we estimated the extent to which dating violence and sexual assault victimization in LGBTQ + adolescents could be reduced by eliminating sexual orientation and gender modality inequities in school adult support, bullying victimization, and family adversity. We analyzed data from a cross-sectional, population-based survey of high school students in Dane County, Wisconsin (N = 15,467; 13% sexual minority; 4% transgender/nonbinary; 72% White) using interventional effects analysis, adjusting for grade, race/ethnicity, and family financial status. We found that eliminating inequities in bullying victimization and family adversity could significantly reduce dating violence and sexual assault victimization in LGBTQ + adolescents, particularly sexual minority cisgender girls and transgender/nonbinary adolescents. For instance, eliminating gender modality inequities in family adversity could reduce sexual assault victimization in transgender/nonbinary adolescents by 2.4 percentage points, representing 27% of the existing sexual assault victimization disparity between transgender/nonbinary and cisgender adolescents (P < 0.001). Results suggest that dating violence and sexual assault victimization in LGBTQ + adolescents could be meaningfully reduced by policies and practices addressing anti-LGBTQ + bullying as well as heterosexism- and cissexism-related stress in LGBTQ + adolescents' families.
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Bullying , Vítimas de Crime , Violência por Parceiro Íntimo , Delitos Sexuais , Adulto , Humanos , Masculino , Feminino , Adolescente , Estudos Transversais , Violência por Parceiro Íntimo/prevenção & controle , Bullying/prevenção & controleRESUMO
OBJECTIVES: The focus of this study was to calculate and contextualize response rates for a community-based study conducted during the COVID-19 pandemic, a topic on which scant data exist, and to share lessons learned from recruiting and enrolling for implementation of future studies. DESIGN: The Life+Health Study, a cross-sectional population-based study designed to advance novel methods to measure and analyze multiple forms of discrimination for population health research. SETTING: The study recruited participants from 3 community health centers in Boston, Massachusetts, between May 2020 and July 2022. PARTICIPANTS: A total of 699 adult participants between the ages of 25 and 64 years who were born in the United States and had visited one of the health centers within the last 2 years. MAIN OUTCOME MEASURES: The response rate was calculated as follows: (number of completions + number of dropouts)/(dropouts + enrollments). To contextualize this response rate, we synthesized evidence pertaining to local COVID-19 case counts, sociopolitical events, pandemic-related restrictions and project protocol adjustments, and examples of interactions with patients. RESULTS: Our study had a lower-than-expected response rate (48.4%), with the lowest rates from the community health centers serving primarily low-income patients of color. Completion rates were lower during periods of higher COVID-19 case counts. We describe contextual factors that led to challenges and lessons learned from recruiting during the pandemic, including the impact of US sociopolitical events. CONCLUSIONS: The Life+Health Study concluded recruitment during the pandemic with a lower-than-expected response rate, as also reported in 4 other US publications focused on the impact of COVID-19 on response rates in community-based studies. Our results provide an example of the impact of the pandemic and related US sociopolitical events on response rates that can serve as a framework for contextualizing other research conducted during the pandemic and highlight the importance of best practices in research recruitment with underserved populations.
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COVID-19 , Adulto , Humanos , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , COVID-19/epidemiologia , Pandemias , Boston/epidemiologia , Estudos Transversais , Centros Comunitários de SaúdeRESUMO
There is growing evidence that people who are transgender and gender diverse (TGD) are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Prior literature has characterized disparities in cardiovascular morbidity and mortality as a result of a higher prevalence of health risk behaviors. Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). This American Heart Association scientific statement reviews the existing literature on the cardiovascular health of people who are TGD. When applicable, the effects of gender-affirming hormone use on individual cardiovascular risk factors are also reviewed. Informed by a conceptual model building on minority stress theory, this statement identifies research gaps and provides suggestions for improving cardiovascular research and clinical care for people who are TGD, including the role of resilience-promoting factors. Advancing the cardiovascular health of people who are TGD requires a multifaceted approach that integrates best practices into research, health promotion, and cardiovascular care for this understudied population.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Fenômenos Fisiológicos Cardiovasculares , Pessoas Transgênero , Transexualidade , Suscetibilidade a Doenças , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Prognóstico , Medição de Risco , Fatores de Risco , Fatores Sexuais , Estresse Fisiológico , Estresse PsicológicoRESUMO
Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortative mixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negative interactions with the health-care system. Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.
Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/estatística & dados numéricos , Minorias Sexuais e de Gênero/psicologia , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Adolescente , Adulto , Antirretrovirais/uso terapêutico , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/psicologia , COVID-19/virologia , Comorbidade , Infecções por HIV/transmissão , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Grupos Minoritários/psicologia , Profilaxia Pré-Exposição/métodos , Fatores de Risco , SARS-CoV-2/genética , Comportamento Sexual/psicologia , Parceiros Sexuais/psicologia , Pessoas Transgênero/psicologia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.
Assuntos
Infecções por HIV , Infecções Sexualmente Transmissíveis , Pessoas Transgênero , Adulto , Feminino , Identidade de Gênero , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Homossexualidade Masculina , Humanos , Recém-Nascido , Masculino , Comportamento Sexual , Parceiros Sexuais , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controleRESUMO
To inform culturally relevant HIV prevention interventions, we explore the complexity of sex work among Peruvian transgender women. In 2015, we conducted twenty in-depth interviews and demographic surveys with transgender women in Lima, Peru to examine how transgender women enact individual- and community-level resistance strategies within a context of pervasive marginalization. Although 40% self-identified as "sex workers," 70% recently exchanged sex for money. Participants described nuanced risk-benefit analyses surrounding paid sexual encounters. Classification of clients as "risky" or "rewarding" incorporated issues of health, violence, and pleasure. Interviews highlighted context-informed decision-making (rejecting disrespectful clients, asserting condom use with specific partner types) demonstrating that motivations were not limited to HIV prevention or economic renumeration, but considered safety, health, attraction, gender validation, hygiene, and convenience. These findings underscore the complex risk assessments employed by Peruvian trans women. These individual-level decision-making and context-specific health promotion strategies represent critical frameworks for HIV prevention efforts.