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.

Childbearing at the margins: A systematic metasynthesis of sexual and gender diverse childbearing experiences.

BACKGROUND: The reproductive and perinatal health of sexual and gender-diverse (SGD) individuals is a research priority area for the National Institutes of Health. Over the past decade, this childbearing population has been the focus of several qualitative studies providing the opportunity to evaluate and synthesize the qualitative literature on SGD childbearing experiences in a metasynthesis. METHODS: We conducted a literature search of four databases to identify original research published from January 2011 through June 2021. These results were augmented by forward and backward searching strategies. Two authors independently screened studies. All qualitative studies of the childbearing experience were eligible. Data were extracted and inductively coded using conventional content analysis, and studies underwent a quality appraisal by two authors. RESULTS: From 2396 articles, 127 full-text articles were screened, and 25 were included in this synthesis. Three overarching themes were identified: (a) Systematic Invisibility; (b) Creating Personhood Through Parenthood; and (c) Resilient Narratives of Childbearing. CONCLUSIONS: Relative to heterosexual and cisgender parents, SGD childbearing parents experience unique structural and interpersonal challenges and employ critically important resilience strategies and coping techniques to manage an overwhelming heterocisnormative experience. These findings provide an important target for health care organizations and professionals to improve SGD perinatal health. In addition, this metasynthesis identified persistent gaps in our understanding of this marginalized childbearing population, which have important implications for reducing health disparities that SGD parents experience.

Sexual orientation in transgender adults in the United States.

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.

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.

Transgender Women's Barriers, Facilitators, and Preferences on Tailored Injection Delivery Strategies to Administer Long-Acting Injectable Cabotegravir (CAB-LA) for HIV Pre-exposure Prophylaxis (PrEP).

Long-acting injectable cabotegravir (CAB-LA) is in advanced stages of clinical trials. Under the standard protocol, CAB-LA is injected into the gluteal muscle by a healthcare provider every eight weeks. To explore transgender women's barriers and facilitators to tailored delivery strategies-including self-injection and injection in "drop-in" centers-we completed in-depth interviews with N = 15 transgender women in New York City. Participants endorsed the alternative delivery methods and the corresponding features we proposed, and expressed likes and dislikes about each. These fell into the following categories: competence (e.g., the person delivering CAB-LA must have skills to do so), convenience (e.g., CAB-LA must be easy to obtain), and privacy or fear of judgement (e.g., participants did not want to feel judged for using CAB-LA by providers or other service consumers). Findings suggest the need to offer CAB-LA to transgender women through multiple delivery protocols.

Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs).

There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.

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).