"There is a paywall to my happiness": the influence of socioeconomic determinants on transgender and gender diverse young adults' experiences with eating disorders.

Transgender and gender diverse (TGD) young adults experience elevated risk for eating disorders (ED), partially due to cissexist discrimination and victimization; less is understood about how socioeconomic determinants contribute to their ED risk. Qualitative data collected from 66 TGD young adults (18-30 years old; 29% self-identified as transgender women, 29% as transgender men, 39% as nonbinary people, and 3% as another gender identity (e.g., mahu)) in eight asynchronous online focus groups explored how socioeconomic determinants in conjunction with other dimensions of identity and lived experience shape disordered eating behavior (DEB) and ED risk. Participants described how economic barriers-including poverty and dependency on others (e.g. parents for health insurance)-and challenges produced by insurance and healthcare systems impeded healthcare access to the detriment of their overall mental health and risk for ED. In addition, participants shared different ways they leveraged financial resources to cope with stress, sometimes in ways that impelled disordered eating behaviors. Finally, participants described how poverty, socioeconomic advantage and disadvantage, and classism compound other systems of oppression (e.g. racism, ableism, weight bias) to adversely impact their general health and ED risk.

Differences in Health Care Experiences among Transgender and Gender Diverse Youth by Gender Identity and Race/Ethnicity.

Transgender and gender diverse (TGD) youth experience significant risk for negative health outcomes, yet few studies exist that address TGD youth's experiences of health care. This paper explores the equitable access and utilization of health care in a sample of TGD youth of diverse gender and racial/ethnic identities. Data for this analysis are from the TGD subsample (n = 1415) of the 2018 Survey of Today's Adolescent Relationships and Transitions (START) Project. We assessed five health care experiences: being insured, having a current health care provider, being out to one's provider, believing your provider was knowledgeable about transgender issues, and barriers to accessing care due to gender identity/expression. We examined the proportion of TGD youth who reported each of these outcomes and within-group differences by gender identity and race/ethnicity using descriptive statistics, logistic regression, and predicted probabilities. When differences were examined by gender identity, barriers to equitable care were consistently more present among transgender females than youth of other gender identities. There were few significant differences by race/ethnicity; however, dual referent models demonstrated barriers to equitable care were particularly evident among Black and Hispanic transgender women. We discuss these findings through the lens of intersectionality and highlight the importance of research and intervention work focused on reducing barriers to equitable care for TGD youth.

Vaping Disparities at the Intersection of Gender Identity and Race/Ethnicity in a Population-Based Sample of Adolescents.

BACKGROUND: Transgender adolescents use vape products (eg, e-cigarettes) at higher rates than cisgender adolescents. Little is known about how these disparities differ from the intersectional perspective of both gender identity and race/ethnicity. METHODS: We examined disparities in past 30-day vaping frequency at the intersection of gender identity and race/ethnicity among adolescents participating in two pooled waves of the population-based California Healthy Kids Survey (N = 953 445; 2017-2019). Generalized linear mixed models included gender identity-by-race/ethnicity interactions and adjusted for potential confounders. Stratified models quantified relationships between gender identity and vaping within race/ethnicity strata and between race/ethnicity and vaping within gender identity strata. RESULTS: Transgender adolescents of color were more likely to report a higher frequency of vaping than cisgender white adolescents. In models stratified by race/ethnicity, transgender adolescents evidenced greater odds of more frequent vaping than cisgender adolescents of the same race/ethnicity; disparities were greatest between transgender and cisgender Black adolescents (adjusted odds ratio [AOR]: 6.05, 95% CI: 4.76-7.68) and smallest between transgender and cisgender white adolescents (AOR: 1.20, 95% CI: 1.06-1.35). In models stratified by gender identity, disparities were greatest between transgender Black and transgender white adolescents (AOR: 2.85, 95% CI: 2.20-3.70) and smallest between transgender multiracial and transgender white adolescents (AOR: 1.28, 95% CI: 1.05-1.58). Similar, though less consistent, patterns emerged for adolescents of color unsure of their gender identity relative to cisgender white adolescents. CONCLUSION: Transgender adolescents of color may be especially vulnerable to vaping disparities. Future research should identify and intervene on causal mechanisms undergirding disparities. IMPLICATIONS: Research finds that transgender adolescents use vape products at higher rates than their cisgender peers, however, little is known about how patterns of adolescent vaping may differ by both gender identity and race/ethnicity, information needed to inform culturally tailored prevention and control initiatives to decrease adolescent vaping disparities. Our analysis of data from a population-based adolescent health survey finds evidence of magnified disparities in vaping frequency among transgender adolescents of color.

"We Deserve Care and we Deserve Competent Care": Qualitative Perspectives on Health Care from Transgender Youth in the Southeast United States.

PURPOSE: Transgender populations experience health inequities that underscore the importance of ensuring access to high quality care. We thematically summarize the health care experiences of transgender youth living in the southeast United States to identify potential barriers and facilitators to health care. DESIGN AND METHODS: Transgender youth recruited from community settings in an urban area of the southeast United States participated in individual interviews (n = 33) and focus groups (n = 9) about protective factors. We conducted a thematic analysis of data from 42 participants who described their experiences seeking and receiving health care. RESULTS: Participants reported a wide range of gender identities. The individual interview sample was majority Black (54.5%) and the mean age was 21.7 years and focus group participants were all white and the mean age was 16.8 years. Participants described numerous barriers to health care, including limited availability of gender affirming care, logistical challenges, such as gatekeeping and cost, concerns about confidentiality in relation to sexual behavior and gender identity, and inadequate cultural competency among providers regarding gender-affirming care. Facilitators included intake procedures collecting chosen pronouns and names and consistent use of them by providers, and open communication, including active listening. CONCLUSIONS: Findings underscore the need for a multi-component approach to ensure both transgender- and youth-friendly care. PRACTICE IMPLICATIONS: Providers and office staff may benefit from transgender cultural competency trainings. In addition, clinic protocols relating to confidentiality and chosen name and pronoun use may help facilitate access to and receipt of quality care.

School Climate Among Transgender High School Students: An Exploration of School Connectedness, Perceived Safety, Bullying, and Absenteeism.

This study used self-administered survey data from seven high schools in Florida with a majority Black and/or Hispanic sample to examine transgender students' perceptions and experiences related to school climate in comparison to cisgender students. Using propensity score matching, a matched analytic sample was created of transgender and cisgender students (n = 542, including 186 transgender youth). Adjusted weighted logistic regression models indicated that transgender students were significantly more likely to report ever being bullied at school, being bullied in the past 3 months, and not going to school ≥3 days during the past 30 days. Transgender students were significantly less likely to report feeling safe at school and having positive perceptions of all five school connectedness items compared to cisgender students. Recent bullying experiences moderated the association between transgender status and past month absences. Findings can inform potential roles for school nurses in improving school climate for transgender youth.

Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students - 19 States and Large Urban School Districts, 2017.

Transgender youths (those whose gender identity* does not align with their sex†) experience disparities in violence victimization, substance use, suicide risk, and sexual risk compared with their cisgender peers (those whose gender identity does align with their sex) (1-3). Yet few large-scale assessments of these disparities among high school students exist. The Youth Risk Behavior Survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2017, 10 states (Colorado, Delaware, Hawaii, Maine, Maryland, Massachusetts, Michigan, Rhode Island, Vermont, Wisconsin) and nine large urban school districts (Boston, Broward County, Cleveland, Detroit, District of Columbia, Los Angeles, New York City, San Diego, San Francisco) piloted a measure of transgender identity. Using pooled data from these 19 sites, the prevalence of transgender identity was assessed, and relationships between transgender identity and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with cisgender males and cisgender females, transgender students were more likely to report violence victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection. These findings indicate a need for intervention efforts to improve health outcomes among transgender youths.

Ensuring Community Participation During Program Planning: Lessons Learned During the Development of a HIV/STI Program for Young Sexual and Gender Minorities.

HIV/STI incidence has shifted to a younger demographic, comprised disproportionately of gay and bisexual men, transgender women, and people of color. Recognizing the importance of community organizing and participatory engagement during the intervention planning process, we describe the steps taken to engage diverse constituents (e.g., youth and practitioners) during the development of a structural-level HIV/STI prevention and care initiative for young sexual and gender minorities in Southeast Michigan. Our multi-sector coalition (MFierce; Michigan Forward in Enhancing Research and Community Equity) utilized a series of community dialogues to identify, refine, and select programmatic strategies with the greatest potential. Evaluation data (N = 173) from the community dialogues highlighted constituents' overall satisfaction with our elicitation process. Using a case study format, we describe our community dialogue approach, illustrate how these dialogues strengthened our program development, and provide recommendations that may be used in future community-based program planning efforts.

Where You Live Matters: Structural Correlates of HIV Risk Behavior Among Young Men Who Have Sex with Men in Metro Detroit.

Structural characteristics are linked to HIV/STI risks, yet few studies have examined the mechanisms through which structural characteristics influence the HIV/STI risk of young men who have sex with men (YMSM). Using data from a cross-sectional survey of YMSM (ages 18-29) living in Detroit Metro (N = 328; 9 % HIV-positive; 49 % Black, 27 % White, 15 % Latino, 9 % Other race), we used multilevel modeling to examine the association between community-level characteristics (e.g., socioeconomic disadvantage; distance to LGBT-affirming institutions) and YMSM's HIV testing behavior and likelihood of engaging in unprotected anal intercourse with serodiscordant partner(s). We accounted for individual-level factors (race/ethnicity, poverty, homelessness, alcohol and marijuana use) and contextual factors (community acceptance and stigma regarding same-sex sexuality). YMSM in neighborhoods with greater disadvantage and nearer to an AIDS Service Organization were more likely to have tested for HIV and less likely to report serodiscordant partners. Community acceptance was associated with having tested for HIV. Efforts to address YMSM's exposure to structural barriers in Detroit Metro are needed to inform HIV prevention strategies from a socioecological perspective.

Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study.

Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.

Gender-Sexuality Alliance Advisors' Self-Efficacy to Address Transgender Issues: An Interpersonal Protective Factor for Transgender Student Depression.

Purpose: Our purpose was to assess the association between Gender-Sexuality Alliances (GSAs) advisors' self-efficacy to address transgender issues and their students' depressive symptoms, by students' gender identity (i.e., transgender vs. cisgender). We predict that higher advisor self-efficacy will be associated with decreases in student depressive symptoms for transgender students, though not necessarily for cisgender students. Methods: Data come from surveys of student members (n = 366) and advisors (n = 58) of 38 purposively sampled GSAs in Massachusetts high schools, in 2016-2017 and 2017-2018. We used a linear mixed-effects model to assess the association between advisor self-efficacy to address transgender issues and student change in Center for Epidemiological Studies Depression-10 scores between the beginning and end of the school year by gender identity, adjusting for student covariates. Results: Students were 10-20 years old (mean = 15, standard deviation [SD] = 1.4); 28% were transgender, 28% were students of color, and 86% were lesbian, gay, bisexual, or queer/questioning or other non-heterosexual identity. The GSA advisor self-efficacy scores ranged from 13 to 25 with a mean of 20.4 (SD = 3.0). Greater advisor self-efficacy to address transgender issues was associated with a decrease in depressive symptoms for transgender students (estimate = -0.47, p = 0.01), but not for cisgender students. Conclusions: GSA advisor self-efficacy to address transgender issues could be protective for transgender student depressive symptoms. Thus, increasing advisor self-efficacy to address transgender issues may help decrease depressive symptomatology for transgender youth, and intervention work in this area is needed to bolster this claim.