"They think we wear loincloths": Spatial stigma, coloniality, and physician migration in Puerto Rico.

Puerto Rico (PR) is facing an unprecedented healthcare crisis due to accelerating migration of physicians to the mainland United States (US), leaving residents with diminishing healthcare and excessively long provider wait times. While scholars and journalists have identified economic factors driving physician migration, our study analyzes the effects of spatial stigma within the broader context of coloniality as unexamined dimensions of physician loss. Drawing on 50 semi-structured interviews with physicians throughout PR and the US, we identified how stigmatizing meanings are attached to PR, its people, and its biomedical system, often incorporating colonial notions of the island's presumed backwardness, lagging medical technology, and lack of cutting-edge career opportunities. We conclude that in addition to economically motivated policies, efforts to curb physician migration should also address globally circulating ideas about PR, acknowledge their roots in coloniality, and valorize local responses to the crisis that are in danger of being lost to history.

On leaving: Coloniality and physician migration in Puerto Rico.

Puerto Rico (PR) has a growing physician migration problem. As of 2009, the medical workforce was composed of 14,500 physicians and by 2020 the number had been reduced to 9,000. If this migration pattern continues, the Island will not be able to meet the recommended physicians per capita ratio proposed by the World Health Organization (WHO). Existing research has focused on the personal motivations for movement to, or permanence in, a particular setting, and social variables that encourage physicians to migrate (e.g., economic conditions). Few studies have addressed the role of coloniality in fostering physician migration. In this article we examine the role of coloniality and its impact on PR's physician migration problem. The data presented in this paper stem from an NIH-funded study (1R01MD014188) that aimed to document the factors associated with physician migration from PR to the US mainland and its impact on the Island's healthcare system. The research team used qualitative interviews, surveys, and ethnographic observations. This paper focuses on the data from the qualitative interviews with 26 physicians who had migrated to the USA and ethnographic observations, which were collected and analyzed between September 2020 and December 2022. The results evidence that participants understand physician migration as a consequence of three factors: 1) the historical and multidimensional deterioration of PR, 2) the idea that the current healthcare system is rigged by politicians and insurance companies, and 3) the specific challenges faced by physicians in training on the Island. We discuss the role of coloniality in fostering these factors and how it serves as the backdrop for the problem faced by the Island.

Recommendations from Latinx Trans and Non-Binary Individuals to Promote Cancer Prevention in Puerto Rico and Florida.

Latinx trans and non-binary individuals (LTNB) face increased cancer-related health disparities. Studies evidence how barriers at the individual, provider and organizational levels drive cancer disparities among LTNB individuals. These barriers increase the emotional discomfort associated with testing and disengagement from cancer prevention efforts. Moreover, there are no guidelines or interventions that address cancer prevention specifically among LTNB individuals. There is a need to develop interventions informed by the LTNB communities to promote cancer prevention and screening. The study aims to describe the recommendations provided by LTNB individuals to foster cancer screening and prevention in the communities residing in Puerto Rico and Florida. We conducted two online focus groups with a total of 15 LTNB participants. Participants were recruited using non-probabilistic purposive sampling. We used rapid-qualitative analysis for data interpretation. Findings are gathered in three main themes: (1) recommendations for promoting cancer prevention screening among providers; (2) specific recommendations to promote cancer screening among LTBN individuals; and (3) recommendations on delivery formats to foster cancer prevention. These results evidence the need and feasibility of developing community informed tailored interventions targeting cancer screening and preventative care to reduce cancer-related health disparities among the LTNB population.

COVID-19 impact on the psychological health of Latinx transgender and non-binary individuals in mainland United States and Puerto Rico: a mixed-methods study.

BACKGROUND: The COVID-19 pandemic continues to generate an unprecedented impact on all aspects of everyday life across the world. However, those with historically and currently marginalized identities (i.e., gender or ethnicity) who already experience a wide range of structural inequities have been disproportionally impacted. LTNB are a particularly at-risk population as they lie at the intersection of race/ethnicity, gender identity, language, migration status, geographical location, among others, which could further increase their COVID-19 and other health-related risks and disparities. The objective of this study was to examine the impact of key social determinants of health (i.e., gender identity, country, health insurance, employment) among a sample of LTNB individuals. METHODS: The team implemented a cross-sectional exploratory design with an online survey technique using the secure web platforms REDcap and SurveyMonkey. A total of 133 participants completed the online survey. Most of the sample self-identified as transwomen (38.8%), transmen (26.3%), and non-binary (21.8%) between the ages of 21 to 72. All participants were Latinx living in either Puerto Rico (47.7%) or mainland United States (52.3%). Descriptive statistics, reliability tests, Mann-Whitney and rapid thematic analysis test were conducted. RESULTS: Findings show that most participants were always (38.1%) or almost always (33.3%) worried about contracting COVID-19. Individuals living in Puerto Rico reported more difficulties than those residing in the mainland US regarding COVID-19 impact on psychosocial, emotional, and COVID-related thinking. Most participants' answers for the COVID-19 open-ended questions focused on three main domains: income, access to trans-affirmative health care, and coping strategies. DISCUSSION: Findings evidence that although most of LTNB participants were negatively impacted by the COVID-19 pandemic in multiple aspects of their lives, those living in Puerto Rico experienced these differently when compared to those in mainland US. More research is needed to understand better the mechanisms and pathways through which this context specifically impacts LTNB health and wellbeing, particularly in Puerto Rico. This study could help shape the public health response taking into account the geographical location and other intersectional identities that play critical roles in the production and reproduction of inequities.

Red tape, slow emergency, and chronic disease management in post-María Puerto Rico.

This paper draws upon the notion of slow emergency as a framework to interpret ethnographic and qualitative findings on the challenges faced by Puerto Ricans with chronic conditions and health sector representatives throughout the island during and after Hurricane María. We conducted participant observation and qualitative interviews with chronic disease patients (n=20) health care providers and administrators (n=42), and policy makers (n=5) from across the island of Puerto Rico in 2018 and 2019. Many Puerto Ricans coping with chronic diseases during and after María experienced bureaucratic red tape as the manifestation of colonial legacies of disaster management and health care. They describe a precarious existence in perpetual "application pending" status, waiting for services that were not forthcoming. Drawing on ethnographically informed case examples, we discuss the effects of these bureaucratic barriers on persons with three chronic conditions: renal disease, opioid dependency, and HIV/AIDS. We argue that while emergency management approaches often presume a citizen-subject with autonomous capacity to prepare for presumably transient disasters and envision a 'post-disaster future' beyond the immediate crisis, Puerto Rican voices draw attention to the longer, sustained, slow emergency of colonial governance.

COVID-19 impact on the psychological health of Latinx transgender and non-binary individuals in mainland United States and Puerto Rico: A mixed-methods study.

Background The COVID-19 pandemic continues to generate an unprecedented impact on all aspects of everyday life across the world. However, those with historically and currently marginalized identities (i.e., gender or ethnicity) who already experience a wide range of structural inequities have been disproportionally impacted. LTNB are a particularly at-risk population as they lie at the intersection of race/ethnicity, gender identity, language, migration status, geographical location, among others, which could further increase their COVID-19 and other health-related risks and disparities. The objective of this study was to examine the impact of key social determinants of health (i.e., gender identity, country, health insurance, employment) among a sample of LTNB individuals. Methods The team implemented a cross-sectional exploratory design with an online survey technique using the secure web platforms REDcap and SurveyMonkey. A total of 133 participants completed the online survey. Most of the sample self-identified as transwomen (38.8%), transmen (26.3%), and non-binary (21.8%) between the ages of 21 to 72. All participants were Latinx living in either Puerto Rico (47.7%) or mainland United States (52.3%). Descriptive statistics, reliability tests, Mann-Whitney and rapid thematic analysis test were conducted. Results Findings show that most participants were always (38.1%) or almost always (33.3%) worried about contracting COVID-19. Individuals living in Puerto Rico reported more difficulties than those residing in the mainland US regarding COVID-19 impact on psychosocial, emotional, and COVID-related thinking. Most participants' answers for the COVID-19 open-ended questions focused on three main domains: income, access to trans-affirmative health care, and coping strategies. Discussion Findings evidence that although most of LTNB participants were negatively impacted by the COVID-19 pandemic in multiple aspects of their lives, those living in Puerto Rico experienced these differently when compared to those in mainland US. More research is needed to understand better the mechanisms and pathways through which this context specifically impacts LTNB health and wellbeing, particularly in Puerto Rico. This study could help shape the public health response taking into account the geographical location and other intersectional identities that play critical roles in the production and reproduction of inequities.

From Necropraxis to Necroresistance: Transgender Experiences in Latin America.

Latin America is one of the deadliest regions for trans communities. Scientific research generated in the region has reported that trans people live through a complicated panorama shaped by multiple forms of oppression, extreme violence, and micro-aggressions. Although necropolitics, as a theoretical approach, has been useful to understand how State policies negatively affect trans individuals, it does not fully account for informal dynamics within groups and among individuals that are potentially lethal for this population in Latin America. To account for this gap, the author proposes two novel concepts: necropraxis (a pattern that manifest itself in everyday social interactions, through which gradual small doses of death are delivered to eliminate, symbolically and/or literally, trans people); and necroresistance (the ways in which trans people defy the threats imposed by necropraxis through "ordinary" acts manifested in their everyday life). The main objective of this article is to put forth definitions for these two concepts and identify how they apply in the context of trans communities in three countries of the region: Guatemala, Argentina, and Chile. To achieve the latter, the author relies on her ethnographic work in these contexts. Data were gathered through parcipant observation, in-depth interviews with trans persons (N = 11) and informal conversations with individuals during the site visits. A deductive qualitative analysis was conducted. Results evidence how the manifestation of necropraxis and necroresistance were highly influenced by the historical, political, economic and sociocultural context of each country. This study provides valuable information to help both policymakers and other stakeholders understand the problem's magnitude in the region and the ways necropraxis is experienced in everyday relations between trans individuals and others. Similarly, through the understanding of what constitutes necroresistance and its value, the proposed framework could help them outline prevention and management strategies to strengthen trans communities in different countries.

The impact of Hurricane Maria on Puerto Rico's health system: post-disaster perceptions and experiences of health care providers and administrators.

BACKGROUND: After its landfall in Puerto Rico in 2017, Hurricane Maria caused the longest blackout in United States history, producing cascading effects on a health care system that had already been weakened by decades of public sector austerity and neoliberal health reforms. This article addresses how health care professionals and administrators experienced the health care system's collapse and the strategies used by them to meet their communities' health needs. METHODS: Data were collected between September 2018 and February 2020. Ethnographic observations in health care facilities and semi-structured qualitative interviews with representatives of the health care system were conducted. This paper focuses on data from interviews with health care providers (n = 10) and administrators (n = 10), and an ethnographic visit to a pop-up community clinic. The analysis consisted of systematic thematic coding of the interview transcripts and ethnographic field notes. RESULTS: Results provide insight on how participants, who witnessed first-hand the collapse of Puerto Rico's health care system, responded to the crisis after Maria. The prolonged power outage and lack of a disaster management plan were partly responsible for the death of 3,052 individuals who experienced extended interruptions in access to medical care. Participants reported a sense of abandonment by the government and feelings of mistrust. They also described the health sector as chaotic and lacking clear guidelines on how to provide services or cope with personal crises while working under extreme conditions. In such circumstances, they developed resilient responses to meet communities' health needs (e.g., itinerant acupuncture services, re-locating physicians to local pharmacies). CONCLUSIONS: Participants' narratives emphasize that the management of Hurricane Maria was fraught with political and economic constraints affecting Puerto Rico. Ineffective planning and post-Maria responses of the local and federal governments were determinants of the disaster's impact. The findings contribute to a growing scientific literature indicating that Hurricane Maria revealed 'the collapse before the collapse,' alluding to the structural deficiencies that presaged the catastrophic event. In the context of governmental abandonment, the authors argue for the importance of developing alternative strategies in post-disaster health care provision among health professionals and administrators who work at the front lines of recovery.

Stigmatizing Experiences of Trans Men in Puerto Rico: Implications for Health.

Purpose: The past decade has seen an increase in efforts aimed at understanding the health needs of the transgender population. In the context of Puerto Rico (PR), those efforts have primarily focused on trans women due to their high human immunodeficiency virus (HIV) incidence. However, due to the low impact of the HIV epidemic among trans men, this remains an understudied population in PR. Thus, it is important that research efforts ad- dress the health care needs of trans men in a range of cultural settings, including PR. Recent literature emphasizes the role of stigmatization as a social determinant associated with deleterious health consequences for diverse groups. Despite this worrisome scenario, little is known about how trans men in PR experience and are negatively impacted by social stigma. The objective of this study was to document the stigmatization experiences faced by trans men in PR and its impact on their overall health. Methods: We conducted an exploratory qualitative study with 29 trans men. We implemented focus groups and in-depth qualitative interviews. Thematic analysis guided our interpretation of the findings. Results: Three categories of stigma are discussed: (1) structural stigmatization, (2) interpersonal stigmatization, and (3) individual stigmatization. The health implications of these stigma experiences are discussed. Conclusion: This study represents an initial step toward understanding the social context of this "invisible" community and its health and well-being. We provide recommendations to address social and health concerns related to this understudied community.

Decolonial visual resistance as a public health strategy in post-María Puerto Rico.

In this article, we explore the use of the image as a strategy to understand how natural disasters and coloniality impact the health of marginalized communities. We focus on the aftermath of Hurricane María in Puerto Rico and aim to describe how local people used the image as a strategy to challenge the invisibility fostered by coloniality and advocate for a more humane, equitable and effective public health response. We implemented a mixed methods research design including: (1) ethnographic observations, (2) qualitative in-depth interviews with 67 representatives of the health care system, (3) photographs they had taken as part of their experiences during and after the hurricane and (4) images from local newspapers and social media. In light of the findings we argue that Puerto Ricans engaged in decolonial visual resistance to manage the aftermath of the hurricane. Thus, while surviving the natural disaster, they challenged the traditional use of the image in public health endeavours.

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience.

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP's utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

Religion and HIV-Related Stigma among Nurses Who Work with People Living with HIV/AIDS in Puerto Rico.

HIV-related stigma among nurses can impact health care services for people with HIV/AIDS (PWHA). health care professionals' religious views can potentially foster stigmatizing attitudes. There is scarce scientific literature exploring the role of religion on HIV/AIDS stigma among nurses. This study aimed to explore the role of religion in the stigmatization of PWHA by nurses in Puerto Rico. We conducted an exploratory study using qualitative techniques. We conducted 40 in-depth interviews with nurses who provided services to PWHA. Three main factors emerged in the analysis as contributors to HIV/AIDS stigmatization: (1) nurses' personal religious experiences, (2) religion as a rationale for HIV-related stigma, and (3) religious practices during health care delivery. The results show that religious beliefs play a role in how nurses understood HIV/AIDS and provided service. Results point toward the need for interventions that address personal religious beliefs while reducing HIV/AIDS stigma among nurses.

The social context of hormone and silicone injection among Puerto Rican transwomen.

This paper draws on ethnographic, qualitative and survey data with transwomen in Puerto Rico to examine the social and political-economic context of lay injection with hormone and silicone - common practices within this community. We describe specific practices of hormone and silicone injection, the actors that govern them, the market for the sale and distribution of syringes and the networks of lay specialists who provide services to a population that is neglected by and largely excluded from biomedical settings. Our data derive from ethnographic observations, sociodemographic questionnaires, surveys and semi-structured interviews conducted with a diverse group of transwomen in metropolitan San Juan, Puerto Rico. Our analysis focuses on four overlapping social domains or processes that shape the practices of lay silicone and hormone injection among transwomen: (1) the circulation of gender transitioning technologies within local and global markets; (2) the tension between the social exclusion of transwomen and their resilient sub-cultural responses; (3) the cultural meanings that shape transwomen's attitudes about injection; and (4) the perceived consequences of injection. We conclude with a discussion of the kinds of intervention and policy changes that would respond to the factors that most endanger transwomen's health.

Experiences of Violence Among Transgender Women in Puerto Rico: An Underestimated Problem.

Violence is a public health concern faced on a daily basis by transgender women. Literature has documented how it adversely affects quality of life and health and in some instances leads to homicide. Considering the lack of research documenting the experiences of violence among transgender women, the objective of this article was to explore manifestations of violence among this population in Puerto Rico. The data presented in this article are part of a larger study on transgender/transsexual health in Puerto Rico. For the purpose of this article we focus on the quantitative data analysis. Participants (N = 59 transgender women) were recruited via respondent driven sampling. Implications and specific recommendations are discussed in light of these findings.

EXPLORING THE FEASIBILITY AND ACCEPTABILITY OF BIOMARKER COLLECTION FOR HIV INFECTION AND CHRONIC STRESS AMONG TRANSWOMEN IN PUERTO RICO.

The assessment of biomarkers related to HIV and chronic stress increases opportunities for the design of more comprehensive research and intervention efforts on the health of transwomen within the context of Health Psychology. In this paper, we present data from a study implemented in Puerto Rico that aimed to: document the feasibility/acceptability of collecting biomarkers for chronic stress and HIV among transwomen; qualitatively document the factors related to the collection of biomarkers in this population; and explore the feasibility of collecting other types of biological specimens from transwomen in future studies. We implemented an exploratory mixed-method study with a sample of 10 transwomen. Quantitative information was gathered via saliva and hair biomarkers for chronic stress and HIV, while qualitative data was obtained via in-depth interviews. Twenty percent had positive results for HIV antibodies and 30% had hair cortisol levels that exceeded the normal range. The main motivations behind the provision of biomarkers were the desire to know about their health; contributing to a better understanding of health in the transgender community; and having previous positive experiences with our research team. We discuss the incorporation of biomarkers as powerful tools to better describe and understand the health of transwomen.

Discrimination and Health among Lesbian, Gay, Bisexual and Trans People in Puerto Rico.

OBJECTIVE: To identify the experiences of discrimination among and the perceived priorities for the health of lesbian, gay, bisexual, and trans (LGBT) people in Puerto Rico (PR). METHODS: Data were collected during the 2013 LGBT Pride Parade in San Juan, using a brief self-administered survey that included questions on sociodemographic characteristics, the disclosure of sexual orientation/gender identity, experiences of discrimination, experiences while receiving social and health services, and perceived healthcare priorities and needs. RESULTS: Most participants reported that they had disclosed their sexual orientation to at least one person. Discrimination due to sexual orientation/gender identity was most frequently reported to have occurred in school settings. At least 25% of the sample reported regular or negative experiences based on sexual orientation/gender identity when receiving government services and when looking for support from relatives. HIV/AIDS, mental health, and sexual health were identified as healthcare priorities. In bivariate analyses, mental health services and aging were the priorities most frequently reported among older participants. HIV/AIDS was the main priority only for gay men; sexual health was the main priority for bisexuals; and mental health was the main priority for lesbians. Most participants reported that their preferred modalities for health service provision were support groups and health education. CONCLUSION: The experiences of discrimination among LGBT people in PR were consistent across age groups and sexual orientation/gender identity. Policies and interventions to address discrimination in different settings are necessary. The findings also suggest the need to prioritize HIV services among gay men and to address mental and sexual health needs among lesbian and bisexual people.

Intersections and evolution of 'Butch-trans' categories in Puerto Rico: Needs and barriers of an invisible population.

Public health research among transgender populations globally has primarily focused on HIV/AIDS. However, trans men remain outside of this conceptual framework, with distinct but overlapping social contexts and needs. In Puerto Rico (PR), the trans men population has remained largely hidden within the 'butch' lesbian community. The objective of this article is to document the identity construction of trans men and 'buchas' (local term to refer to butch lesbians) in PR and its relation to their bodily practices and overall health. We conducted an exploratory qualitative study with 29 trans men and buchas based on ethnographic observation, focus groups, audio-recorded in-depth interviews, and critical discourse analysis. Findings emphasise two domains to be addressed by health policies and initiatives: (1) bodily representations and gender performance, and (2) the meanings of female biological processes. This small-scale ethnographic study represents an initial step towards understanding the social context of this 'invisible' community and significant implications for their health and well-being. We provide several recommendations to address public health concerns of this understudied, marginalised community.

The role of emotions in the reduction of HIV/AIDS stigma among physicians in training.

Scientific literature has systematically documented the negative effects of social stigma for people living with HIV/AIDS (PLWHA). HIV/AIDS stigma has the potential to negatively impact self-care strategies for those already affected, and simultaneously hinder prevention efforts to deter the emergence of new infections. When health professionals manifest these negative attitudes access to quality health-care and prevention strategies can be seriously affected. Scientifically tested interventions to reduce HIV/AIDS stigma among health professionals are still scarce. Although the number of tested interventions has increased over the past decade, few of them target Latino health professionals or Spanish-speaking populations. Furthermore, although some of those interventions have been reported as effective for stigma reduction, more work is needed to better understand the underlying variables that account for the reduction of stigma attitudes in those efforts. The SPACES intervention has been documented as an effective HIV/AIDS stigma-reduction intervention focusing on health-care professionals in training. The intervention, which is delivered in Spanish, has been previously tested with medical students in Puerto Rico and shown significant results in addressing negative attitudes toward PLWHA. The main objective of this study was to document the underlying variables that fostered reduction of HIV/AIDS stigma due to participation in the SPACES intervention. Results evidence that health professionals in training who participated in the intervention (n = 507) had less stigmatizing attitudes toward PLWHA due to an increase in their positive emotions toward this population. In light of these results, we discuss the importance of engaging health professionals in HIV/AIDS stigma-reduction interventions that go beyond the provision of information and skills for interacting with PLWHA, and address the emotional component of HIV/AIDS stigma.

Testing the efficacy of an HIV stigma reduction intervention with medical students in Puerto Rico: the SPACES project.

INTRODUCTION: Stigma associated with HIV has been documented as a barrier for accessing quality health-related services. When the stigma manifests in the health care setting, people living with HIV receive substandard services or even be denied care altogether. Although the consequences of HIV stigma have been documented extensively, efforts to reduce these negative attitudes have been scarce. Interventions to reduce HIV stigma should be implemented as part of the formal training of future health care professionals. The interventions that have been tested with health care professionals and published have several limitations that must be surpassed (i.e. lack of comparison groups in research designs and longitudinal follow-up data). Furthermore, Latino health care professionals have been absent from these intervention efforts even though the epidemic has affected this population disproportionately. METHODS: In this article, we describe an intervention developed to reduce HIV stigma among medical students in Puerto Rico. A total of 507 medical students were randomly introduced into our intervention and control conditions. RESULTS: The results show statistically significant differences between the intervention and control groups; intervention group participants had lower HIV stigma levels than control participants after the intervention. In addition, differences in HIV stigma levels between the groups were sustained for a 12-month period. CONCLUSION: The results of our study demonstrate the efficacy of the modes of intervention developed by us and serve as a new training tool for future health care professionals with regard to stigma reduction.