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

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

Évolution de la prévalence et de l'incidence de la dysphorie de genre en France depuis 2013 à partir des bases médico-administratives.

INTRODUCTION: In France, trans people can benefit from the coverage of care related to their trans-identity in Long Term Affection (Affection Longue Durée ALD) under the code F64. PURPOSE OF RESEARCH: The aim of this article is to estimate the prevalence and the incidence of trans people in transition from the medical and administrative reimbursement databases in France. RESULTS: In 2020, 8952 persons were in ALD F64. The prevalence was 1.50/100 000 in 2013 and 14.09/100 000 in 2020 all ages combined. Among 0-17 year olds, the increase of prevalence was the greatest (36.75-fold increase). The 18-35 year olds were the largest numbers (459 in 2013 vs 6148 in 2020) with a 12.69 fold increase in prevalence. The incidence has increased by a factor of 8. The incidence of the 0-17 year olds has increased by a factor of 29.45 in 6 years, those of the 18-35 year olds by a factor of 10.63. Overall, more MtF than FtM are observed except in minors and young adults. CONCLUSIONS: There is an overall increase of people with ALD F64 but more marked in minors and young adults. The MtF/FtM ratio is still higher than 1 but tends to be closer to it. It is reversed in minors and young adults.

Initial Clinical Needs Among Transgender and Non-binary Individuals in a Large, Urban Gender Health Program.

BACKGROUND: Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae. OBJECTIVE: To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program. DESIGN: We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation. PARTICIPANTS: We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020. MAIN MEASURES: Clients reported all the types of care in which they were interested at the time of intake as their "reason for call" (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns). KEY RESULTS: Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason. CONCLUSIONS: Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals.

The Epidemiology of Gender Dysphoria in Iran: The First Nationwide Study.

Gender dysphoria (GD) is defined as a persistent and distressful incongruence between one's gender identity and one's at-birth-assigned sex. Sex reassignment has been religiously accepted for transgender individuals in postrevolutionary Iran since 1987; however, very little is known about how many individuals seek and receive such treatment annually. This study provides the first nationwide effort to assess the prevalence of GD in Iran as a function of diagnosis. The medical records of all transgender individuals referred to the Iranian Legal Medicine Organization between March 2012 and March 2017 were reviewed. All individuals diagnosed with GD were contacted. A total of 839 medical records meeting study criteria were received and evaluated. The prevalence of transgender individuals was estimated to be 1.46 per 100,000 Iranians with a transwoman (TW)/ transman (TM) ratio of 1:2. The mean age of individuals with GD at the time of referral was 25.22 (SD = 6.25) years for TW and 25.51 (SD = 5.66) years for TM. The findings are twofold. First, gender dysphoria is less prevalent in Iran than has been reported in Western countries. Second, the sex ratio is skewed toward at-birth-assigned females, which differs from what has been reported in Western countries. These findings have been interpreted in light of Iran's legal system, which is based on Islamic penal codes. These findings are of utmost importance for both health providers and legislators, as it can illustrate a more accurate picture of the transgender population in Iran.

Validating Data-Driven Methods for Identifying Transgender Individuals in the Veterans Health Administration of the US Department of Veterans Affairs.

We sought to operationalize and validate data-driven approaches for identifying transgender individuals in the Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) through a retrospective analysis using VA administrative data from 2006-2018. Besides diagnoses of gender identity disorder (GID), a combination of non-GID data elements was used to identify potentially transgender veterans, including 1) an International Classification of Diseases (Ninth or Tenth Revision) code of endocrine disorder, unspecified or not otherwise specified; 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy); and 3) a change in the veteran's administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VHA of the VA between January 2006 and December 2018. We identified 10,769 potentially transgender veterans. Based on a high positive predictive value for GID-coded veterans (83%, 95% confidence interval: 77, 89) versus non-GID-coded veterans (2%, 95% confidence interval: 1, 11) from chart review validation, the final analytical sample comprised only veterans with a GID diagnosis code (n = 9,608). In the absence of self-identified gender identity, findings suggest that relying entirely on GID diagnosis codes is the most reliable approach for identifying transgender individuals in the VHA of the VA.

Endocrinological and ovarian histological investigations in assigned female at birth transgender people undergoing testosterone therapy.

RESEARCH QUESTION: What are the hormonal and ovarian histological effects of a gender affirming hormonal therapy in assigned female at birth (AFAB) transgender people? DESIGN: Prospective observational study of 70 AFAB transgender people taking testosterone therapy before gender-affirming surgery (hystero-oophorectomy). A gynaecological ultrasonographic scan was undertaken and serum hormone concentrations measured, including anti-Müllerian hormone (AMH) and androgenic profile. Histological ovarian evaluation was assessed in both ovaries, including the developmental stages of the follicles. RESULTS: The mean age of the population was 27.7+/-5.14 years. The main biochemical parameters were total testosterone levels 781.5 ± 325.9 ng/dl; AMH levels 3.2 ± 1.4 ng/ml; FSH and LH levels 4.9 ± 2.5 IU/l and 3.9 ± 2.9 IU/l, respectively; and oestradiol values 47.6 ± 13.7 pg/ml. Fifty-five AFAB underwent gynaecological ultrasound before surgery and antral follicles were found in 43 out of 47 ultrasounds (91.5%) (without the presence of a dominant follicle or corpus luteum). Histological follicles were mostly in the primordial stage (88.0) and 3.3% were atretic. The thickness of the tunica albuginea was widely heterogeneous (range 0.15-1.45 mm) and luteinization of the stromal cells was observed in 68.6% of the samples. A negative correlation between testosterone levels and total antral follicles was found (Rs= -0.306, P = 0.029). CONCLUSIONS: AFAB transgender people taking testosterone therapy show cortical follicle distribution in the range previously reported in fertile cisgender women of reproductive age. The follicular population may not be altered as a result of the gender-affirming hormonal therapy, although some cortical and stromal changes have been observed.

Reproductive functions and fertility preservation in transgender women: a French case series.

RESEARCH QUESTION: The reproductive potential of transgender people may be impaired by gender-affirming hormone treatment (GAHT) and is obviously suppressed by gender-affirming surgery involving bilateral orchiectomy. The evolution of medical support for transgender people has made fertility preservation strategies possible. Fertility preservation in transgender women mainly relies on sperm cryopreservation. There are few studies on this subject, and the sample sizes are small, and so it difficult to know whether fertility preservation procedures are feasible and effective in trans women. DESIGN: This retrospective study reports the management of fertility preservation in transgender women referred to the study centre for sperm cryopreservation, and the semen parameters of trans women were compared with those of sperm donors. RESULTS: Ninety-six per cent of transgender women who had not started treatment benefitted from sperm cryopreservation, compared with 80% of those who attempted a therapeutic window and 50% of those receiving hormonal treatment at the time of sperm collection. No major impairment of semen parameters was observed in transgender women who had not started GAHT compared with sperm donors. However, even though the frequency of oligozoospermia was no different, two transgender women presented azoospermia. Some transgender women who had started GAHT could benefit from sperm freezing. None of them were treated with gonadotrophin-releasing hormone (GnRH) analogues. CONCLUSIONS: Parenthood strategies for transgender people have long been ignored, but this is an important issue to consider, especially because medical treatments and surgeries may be undertaken in adolescents or very young adults. Fertility preservation should ideally be offered prior to initiation of GAHT.

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

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.

The Effects of Methamphetamine Use on the Sexual Lives of Gender and Sexually Diverse People in Dhaka, Bangladesh: A Qualitative Study.

Methamphetamine use has increased among gender and sexually diverse people in several countries, including Bangladesh. This study aimed to explore the effects of methamphetamine on the sexual lives of these people in Dhaka, Bangladesh. An exploratory qualitative study was conducted, comprising 30 in-depth interviews with gender and sexually diverse people including males having sex with males, male sex workers, and transgender women (hijra) under HIV intervention coverage. Ten key informant interviews were also conducted with individuals who have expertise in relevant disciplines such as drug use, harm reduction, and HIV and AIDS. Digitally recorded data were manually analyzed under the thematic analysis framework. Findings indicated that many participants reported that methamphetamine brought changes in their sexual lives such as increased sexual drive, engagement in group sex, the increased ability to perform serial sex, transactional sex, impulsive and coercive sex, initiation and switching of male-to-male sexual practices, and limited condom use. Key informants noted that there is a dearth of methamphetamine-related services in Bangladesh. Methamphetamine use was found to lead to diverse effects on the sexual lives of gender and sexually diverse people, thus making it a driving force for shaping sexual practices and, hence, sexual risks. Therefore, it is essential for policy-level stakeholders and program managers to consider the risks of methamphetamine use due to their negative ramifications on sexual health, including HIV risks.

Psychopathological symptoms in Spanish subjects with gender dysphoria. A cross-sectional study.

BACKGROUND: Most people with gender dysphoria have to face various stressful conditions, which make them more vulnerable to the development of psychopathological symptoms. AIMS: The main goal was to compare psychopathological symptoms between individuals with gender dysphoria and those from the general population. Other secondary aims were to determine if there were differences between gender [male to females (MtFs) and female to males (FtMs)] and also according to cross-sex hormone therapy. METHOD: Symptom Checklist 90 Revised (SCL-90-R) questionnaire was administered to a sample of 205 subjects with gender dysphoria (MtFs = 129 and FtMs = 76). The control group included 530 individuals from the general population who took part in the Spanish validation of the SCL-90-R questionnaire. RESULTS: Overall, individuals with gender dysphoria had higher scores on all SCL-90-R dimensions than the general population, except in the dimension of somatization, in which MtF and FtM subjects scored statistically higher than control males but not than control females. The mean scores of all dimensions except Depression (mean score of 1.17) were below 1, that is, between 0 (not at all) and 1 (occasionally). All dimensions did not differ when comparing MtFs and FtMs nor when comparing gender dysphoric subjects with or without cross-sex hormonal therapy. CONCLUSIONS: The results suggested that most subjects with gender dysphoria attending a gender unit reported higher levels of psychopathology than the general population. However, the scores were indicative of the lack of any clinically relevant psychopathological symptoms.

[Changes of sex ratio and prevalence in transgender teenagers over the past 15 years]. / Transidentität in Jugend und Adoleszenz: Zur Veränderung der Sexratio und der Prävalenz in den letzten eineinhalb Jahrzehnten.

Changes of sex ratio and prevalence in transgender teenagers over the past 15 years Abstract. Evaluation of authors' 1434 expert opinions from 2005-2019 on transgender applicants (420 younger than 20 years old) for legal change of name and gender according to German "Law on Transsexuality" showed (1) in teenage applicants substantial changes of sex ratio from 2:1 to 10:1 in favour of transmales; (2) while prevalence of teenage transfemales during this period remained unchanged, prevalence of transmales rose significantly. According to our data, transgender teenagers are nowadays primarily natal females. Clinical and sociocultural aspects of these changes are discussed.

Increasing normality-persisting barriers: Current socio-demographic characteristics of 350 individuals diagnosed with gender dysphoria.

INTRODUCTION: The number of individuals requesting medical treatment for gender dysphoria has increased significantly within the past years. Our purpose was to examine current biographic and socio-demographic characteristics and aspects of legal gender reassignment. DESIGN: Medical files from n = 350 individuals of a German Endocrine outpatient clinic were collected from 2009 to 2017 and analysed retrospectively. RESULTS: Ratio of transwomen to transmen equates to 1:1.89 with a remarkable increase of transmen by the year 2013, showing a reversal of gender distribution compared with previous studies for the first time. Use of illegal substances or self-initiated hormone therapy was rare (4.6 and 2.1%). Satisfaction with gender-affirming hormone therapy was significantly higher in transmen than in transwomen (100% vs 96.2%, P = .005). Use of antidepressants declined significantly after onset of hormone treatment in transmen (13% vs 7%; P = .007). The number of individuals with a graduation diploma was only about half as high as in the general population (14.3% vs 27.3%), whereas unemployment rate was more than twice as high (14% vs 6.9%). Median latency between application for legal gender reassignment and definitive court decision was 9 months. CONCLUSIONS: Our data provide possible indications for a decline of psychosocial burden in individuals diagnosed with gender dysphoria over the last years. However, affected individuals are still limited in their occupational and financial opportunities as well as by a complex and expensive procedure of legal gender reassignment in Germany.

Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria.

Purpose: To assess how adolescent development progresses and psychiatric symptoms develop among transsexual adolescents after starting cross-sex hormone treatment.Materials and methods: Retrospective chart review among 52 adolescents who came into gender identity assessment before age 18, were diagnosed with transsexualism and started hormonal gender reassignment. The subjects were followed over the so-called real-life phase of gender reassignment.Results: Those who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life. Those who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life.Conclusion: Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016.

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

Reduction in Gaps in High CD4 Count and Viral Suppression Between Transgender and Cisgender Persons Living With HIV in New York City, 2007-2016.

Objectives. To compare trends in HIV outcomes for cisgender and transgender persons living with HIV (PLWH) in New York City.Methods. We used HIV surveillance data for the analysis. We based CD4 count on the last measurement in a calendar year and defined viral suppression as the last viral load being less than or equal to 200 copies per milliliter in the calendar year.Results. The estimated number of PLWH increased from 73 415 in 2007 to 83 299 in 2016, including 606 transgender persons (0.8%) in 2007 and 1054 transgender persons (1.3%) in 2016. The proportion with CD4 count of 500 cells per cubic millimeter or more increased from 38% in 2007 to 61% in 2016 among cisgender persons versus 32% to 60% among transgender persons. The proportion with a suppressed viral load increased from 52% in 2007 to 80% in 2016 among cisgender persons versus 42% to 73% among transgender persons.Conclusions. Among PLWH in New York City, CD4 count and viral suppression improved during 2007 to 2016, with larger improvements among transgender persons, leading to narrower gaps. However, continuing efforts to improve HIV outcomes among transgender PLWH are needed to further eliminate disparities, particularly in viral suppression.

Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006-2017.

Background. Transgender women (transwomen) in the United States have been shown to have high HIV risk with Black and Hispanic transwomen being particularly vulnerable. Growing research on transgender men (transmen) also shows increased HIV risk and burden, although not as much is known for this transgender population.Objectives. This systematic review estimates the prevalence of self-reported and laboratory-confirmed HIV infection, reported sexual and injection behaviors, and contextual factors associated with HIV risk of transgender persons living in the United States.Search Methods. We searched the HIV Prevention Research Synthesis database and MEDLINE, EMBASE, PsycINFO, CINAHL, and Sociological Abstracts databases from January 2006 to March 2017 and January 2006 to May 2017, respectively. Additional hand searches were conducted in December 2017 to obtain studies not found in the literature searches.Selection Criteria. Eligible reports were published US-based studies that included transgender persons and reported HIV status.Data collection and analysis. Data were double-coded and quality assessed. We used random-effects models employing the DerSimonian-Laird method to calculate overall prevalence of HIV infection, risk behaviors, and contextual factors for transwomen, transmen, and race/ethnicity subgroups.Main Results. We reviewed 88 studies, the majority of which were cross-sectional surveys. Overall laboratory-confirmed estimated prevalence of HIV infection was 9.2% (95% confidence interval [CI] = 6.0%, 13.7%; κ = 24). Among transwomen and transmen, HIV infection prevalence estimates were 14.1% (95% CI = 8.7%, 22.2%; κ = 13) and 3.2% (95% CI = 1.4%, 7.1%; κ = 8), respectively. Self-reported HIV infection was 16.1% (95% CI = 12.0%, 21.2%; κ = 44), 21.0% (95% CI = 15.9%, 27.2%; κ = 30), and 1.2% (95% CI = 0.4%, 3.1%; κ = 7) for overall, transwomen, and transmen, respectively. HIV infection estimates were highest among Blacks (44.2%; 95% CI = 23.2%, 67.5%; κ = 4). Overall, participation in sex work was 31.0% (95% CI = 23.9%, 39.0%; κ = 39). Transwomen (37.9%; 95% CI = 29.0%, 47.7%; κ = 29) reported higher participation in sex work than transmen (13.1%; 95% CI = 6.6%, 24.3%; κ = 10; P = .001). Most outcomes indicated high heterogeneity in the overall and subgroup analyses.Conclusions. The availability of more data allowed us to calculate estimates separately for transwomen and transmen. HIV prevalence estimates for US transwomen were lower than previous estimates, but estimates for HIV prevalence and participation in sex work were higher when compared with transmen. Evidence gaps remain for transmen and the syndemic relationship of HIV, risky behaviors, and contextual factors specific to the transgender experience.Public Health Implications. This study highlights gender disparities for HIV and risky sexual behavior, as well as evidence gaps that exist for transmen. Tailored programs and services for the transgender population need to be developed to encourage use of and access to HIV prevention services.

Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study.

INTRODUCTION: Studies about sexual functioning in trans persons have mainly focused on sexual functioning after genital gender-affirming surgery, have had small sample sizes, and have not explored the broad range of possible sexual dysfunctions. Measuring sexual functioning in trans persons during transitioning is important to determine the kind of care trans persons may need in order to regain their sexual health. AIM: The first aim of the present study was to explore the prevalence of sexual function disturbances and dysfunctions (with distress) in trans women and trans men 4 to 6 years after initial clinical entry. The second aim was to compare the prevalence of sexual dysfunctions among the various treatment trajectories and between trans persons with or without further genital treatment intentions. METHODS: An online follow-up questionnaire was filled out by 518 trans persons (307 identifying predominantly feminine, 211 identifying predominantly masculine) as a part of the European Network for the Investigation of Gender Incongruence initiative. All participants had their initial clinical appointments in gender clinics in Ghent, Amsterdam, or Hamburg. MAIN OUTCOME MEASURE: The main outcome measures were the prevalence of sexual dysfunctions and medical treatment data, measured via self-report items. RESULTS: The most frequent sexual dysfunctions experienced by trans women and trans men were difficulties initiating and seeking sexual contact (26% and 32%, respectively) and difficulties achieving an orgasm (29% and 15%, respectively). Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire. Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often. No significant differences were found between participants with or without further genital treatment intentions. CLINICAL IMPLICATIONS: Clinicians should consider sexual counseling after medical treatments, paying particular attention to potential social and psychological barriers to the sexual health of their patients. STRENGTHS & LIMITATIONS: This study included all trans persons irrespective of treatment decisions, and focused on a broad range of potential sexual difficulties taking the distress criteria into account. Limitations include the cross-sectional design, the limited power for the comparison of treatment groups and the absence of validated questionnaires about sexual functioning for transgender persons. CONCLUSION: Sexual dysfunctions among trans men and women were very common among the various treatment groups and were unrelated to intentions to have further genital treatment. Although medical treatment may be helpful or even essential to developing good sexual health, a significant group of trans persons experienced sexual dysfunctions after genital surgery. Kerckhof ME, Kreukels BPC, Nieder TO, et al. Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study. J Sex Med 2019; 16:2018-2019.

A social systems analysis of implementation of El Salvador's national HIV combination prevention: a research agenda for evaluating Global Health Initiatives.

BACKGROUND: Global Health Initiatives (GHIs) have been instrumental in the rapid acceleration of HIV prevention, treatment access, and availability of care and support services for people living with HIV (PLH) in low and middle income countries (LMIC). These efforts have increasingly used combination prevention approaches that include biomedical, behavioral, social and structural interventions to reduce HIV incidence. However, little research has evaluated their implementation. We report results of qualitative research to examine the implementation of a national HIV combination prevention strategy in El Salvador funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. METHODS: We conducted in-depth interviews with principal recipients of the funding, members of the Country Coordinating Mechanism (CCM) and front line peer outreach workers and their clients. We analyzed the data using a dynamic systems framework. RESULTS: El Salvador's national HIV combination prevention strategy had three main goals: 1) to decrease the sexual risk behaviors of men who have sex with men (MSM), commercial sex workers (CSW) and transgender women (TW); 2) to increase HIV testing rates among members of these populations and the proportion of PLH who know their status; and 3) to improve linkage to HIV treatment and adherence to antiretroviral therapy (ART). Intervention components to achieve these goals included peer outreach, community prevention centers and specialized STI/HIV clinics, and new adherence and retention protocols for PLH. In each intervention component, we identified several factors which reinforced or diminished intervention efforts. Factors that negatively affected all intervention activities were an increase in violence in El Salvador during implementation of the strategy, resistance to decentralization, and budget constraints. Factors that affected peer outreach and sexual risk reduction were the human resource capacity of grassroots organizations and conflicts of the national HIV strategy with other organizational missions. CONCLUSIONS: Overall, the national strategy improved access to HIV prevention and care through efforts to improve capacity building of grass roots organizations, reduced stigma, and improved coordination among organizations. However, failure to respond to environmental and organizational factors limited the intervention's potential impact.

Critical consciousness moderates the relationship between transphobia and "bathroom bill" voting.

In recent years, antitransgender legislation that focuses on gender and the use of public restrooms-so-called bathroom bills-has been considered in many states in the United States. The present study was designed to extend research on transphobic attitudes and elucidate links between religious fundamentalism, social dominance orientation, transphobia, and voting for bathroom bills. Further, we examined the moderating influence of critical consciousness on the relationship between transphobic attitudes and voting on a hypothetical bathroom bill. Results of a moderated mediation multinomial logistic regression path analysis using data from a sample of 282 college students (154 women and 128 men) indicated that religious fundamentalism and social dominance orientation were associated with transphobic attitudes. Transphobia was associated with lower likelihood to vote against or abstain from voting on the bill, compared to voting for it. Critical consciousness was also associated with greater likelihood of voting against the bill rather than for it. The interaction between transphobia and critical consciousness was associated with voting against rather than for the bill, such that at higher levels of transphobia, those higher in critical consciousness were more likely to vote against the bill rather than for it. Implications for incorporating critical consciousness into advocacy efforts to promote transgender rights are discussed. (PsycINFO Database Record

Safe Schools? Transgender Youth's School Experiences and Perceptions of School Climate.

The magnitude of gender identity-related disparities in school-based outcomes is unknown because of a lack of representative studies that include measures of gender identity. By utilizing a representative sample generalizable to a broader population, this study elucidates the size of gender identity-related disparities, independent of sexual orientation, in school experiences associated with school connectedness and perceptions of school climate. Additionally, the inclusion of and comparison to results of a large non-representative sample allows for more direct comparisons to previous studies of the school experiences of transgender youth. The analyses in this study primarily draw on a sample of 31,896 youth representative of the middle and high school population in California who participated in the 2013-2015 California Student Survey (a subsample of the California Healthy Kids Survey, which includes the largest known sample of transgender youth). Over half the sample identified their sex as female (51.3%), and 398 identified as transgender (1.0%). The sample was racially and ethnically diverse: 30.7% identified as multiracial, 33.0% as White, 11.1% as Asian, 7.4% as Black, and 52.9% as Hispanic. Findings from multilevel analyses show that relative to non-transgender youth, transgender youth were more likely to be truant from school, to experience victimization and bias-based bullying, and to report more negative perceptions of school climate, though did not differ in self-reported grades. The findings have implications for improving school policies and practices to create safer and more supportive school climates for all youth.