Gynecological Care Among Brazilian Women Who Have Sex with Women: A Respondent-Driven Sampling Study.

Purpose: This study aimed to describe the gynecological care provided to Brazilian women who have sex with women (WSW). Methods: Respondent-driven sampling was used to recruit Brazilian WSW. The survey questions, concerning gynecological care, were designed in Portuguese by medical professionals, medical students, and LGBTQIA+ community members, including the authors. The statistical analyses were weighted to account for the likelihood of recruitment. Results: From January to August of 2018, 299 participants were recruited in 14 recruitment waves. The mean age of the WSW was 25.3 years. Most (54.9%) identified as lesbian and had been involved in past-year sexual intercourse mainly with cisgender women (86.1%). The WSW also reported having sex with cisgender men (22.2%), transgender men (5.3%), nonbinary people (2.3%), and transgender women (5.3%) in the last year. More than a quarter of the WSW did not have regular appointments with a gynecologist: 8.0% (95% confidence interval [CI] = 4.2-11.6) and 19% (95% CI = 12.8-25.2) stated that they had never gone to the gynecologist or they had only gone for emergencies, respectively. Almost one-third had never had cervical cancer screening (cervical cytology, Pap test or Pap smear). Most women justified avoiding the test because they felt healthy, thought it would hurt, or feared a health professional might mistreat them. Conclusion: Gynecologists should avoid heteronormative assumptions, inquire about sexual practices, orientation, and identity separately, and provide Pap tests as advised to WSW.

"¿Por qué pasa esto? Porque vivimos en una sociedad que constantemente te dice que no eres mujer": género y riesgo del VIH en mujeres trans del noreste mexicano / "Why did this happen? Because we live in a society that constantly says that you are not a woman": gender and HIV risk in trans women in Northeast Mexico / "Por que isso está ocorrendo? Porque estamos vivendo em uma sociedade que constantemente te diz que você não é mulher": gênero e risco de HIV em mulheres trans do nordeste mexicano

Las mujeres trans enfrentan un riesgo desproporcionado de adquirir el VIH. Este estudio analiza cualitativamente el riesgo del VIH en mujeres trans mexicanas desde el género como estructura social. Se trata de un estudio cualitativo realizado en el noreste de México. Se hicieron 15 entrevistas a mujeres trans de entre 22 y 69 años y se realizó un análisis temático. El análisis de las entrevistas reveló tres categorías temáticas: construcciones sociales del VIH y estigma, el género y el VIH en las relaciones interpersonales, y el género y el VIH en las instituciones y la política. Los resultados muestran que las construcciones sociales del VIH se tejen en el colectivo, a partir de la interacción con otras mujeres trans. El VIH es un fenómeno atravesado por la temporalidad sociohistórica y, en ese sentido, se generan las percepciones de riesgo frente a él. El género como estructura de opresión se vincula con las experiencias de estigma y discriminación, así como la búsqueda de la legitimación del género a través de las relaciones con parejas sexuales. Las instituciones y la política pública se relacionan con el acceso a los servicios de salud, además se identifican y analizan las barreras institucionales, personales y colectivas a partir de la identidad de género. La política sostiene y refuerza la marginalización de las mujeres trans impactando en el riesgo del VIH. Los resultados muestran que el riesgo del VIH es un fenómeno multicausal basado en el género como estructura de opresión con implicaciones sistémicas.

Trans women experience disproportionate risk of HIV infection. The study performed a qualitative analysis of HIV risk in Mexican trans women from the perspective of gender as social structure. The qualitative study was performed in Northeast Mexico. Fifteen interviews were performed with trans women 22 to 69 years of age, followed by thematic analysis. The analysis revealed three thematic categories: social constructs of HIV and stigma, gender and HIV in interpersonal relations, and gender and HIV in institutions and policy. The results show that social constructs of HIV are produced collectively based on interaction with other trans women. HIV is a phenomenon traversed by sociohistorical temporality, generating risk perceptions. Gender as a structure of oppression is linked to experiences of stigma and discrimination and the search for gender legitimization through relations with sex partners. Institutions and public policy relate to access to health services, and institutional, personal, and collective barriers are identified and analyzed based on gender identity. The policy sustains and reinforces the marginalization of trans women, impacting HIV risk. HIV risk is a multicausal phenomenon based on gender as a structure of oppression with systemic implications.

As mulheres trans enfrentam um risco desproporcional de adquirir HIV. Este estudo analisa qualitativamente o risco do HIV em mulheres trans mexicanas a partir do gênero como estrutura social. Trata-se de um estudo qualitativo realizado no nordeste de México. Foram realizadas 15 entrevistas com mulheres trans, com idade entre 22 e 69 anos, além de uma análise temática. A análise das entrevistas revelou três categorias temáticas: construções sociais do HIV e estigma, gênero e HIV nas relações interpessoais, e gênero e HIV nas instituições e a política. Os resultados mostram que as construções sociais do HIV se consolidam no coletivo, a partir da interação com outras mulheres trans. O HIV é um fenómeno atravessado pela temporalidade socio histórica e, neste sentido é que são geradas as percepções de risco frente a ele. O gênero como estrutura de opressão está relacionado às experiências de estigma e discriminação, e a busca da legitimação do gênero através das relações com parceiras sexuais. As instituições e a política pública são relacionadas com o acesso aos serviços de saúde e se identificam e analisam as barreiras institucionais, pessoais e coletivas, a partir da identidade de gênero. A política apoia e reforça a marginalização das mulheres trans, impactando o risco do HIV. Os resultados mostram que o risco do HIV é um fenómeno multicausal baseado gênero como estrutura de opressão com desdobramentos sistémicos.

Tobacco use among transgender and gender non-binary youth in Brazil.

Transgender and gender non-binary youth are particularly vulnerable to tobacco smoking and susceptible to smoking adverse health outcomes. That is, they are in special risk to start smoking and, after starting, they may face worse outcomes when comparing to their cisgender peers. Therefore, the present study aims to evaluate factors associated with tobacco use among transgender and gender non-binary youth. Brazilian youth aged 16 to 25 who identify as transgender or gender non-binary answered an online questionnaire. Poisson regression with robust variance was run to predict smoking cigarettes based on individual and environmental factors. 14.1% of 206 youth reported smoking cigarettes daily, whereas 9.3% of participants reported smoking e-cigarettes occasionally. Drug use, lack of social support, deprivation, discrimination, the wait for medical gender-affirming procedures and being outside school were associated with smoking cigarettes. Contextual and individual factors should be further explored in causal analysis and taken into consideration when planning smoking prevention and cessation interventions for transgender and gender non-binary youth.

Tobacco use among transgender and gender non-binary youth in Brazil / Uso de tabaco entre jovens transgêneros e não-binários do Brasil

Abstract Transgender and gender non-binary youth are particularly vulnerable to tobacco smoking and susceptible to smoking adverse health outcomes. That is, they are in special risk to start smoking and, after starting, they may face worse outcomes when comparing to their cisgender peers. Therefore, the present study aims to evaluate factors associated with tobacco use among transgender and gender non-binary youth. Brazilian youth aged 16 to 25 who identify as transgender or gender non-binary answered an online questionnaire. Poisson regression with robust variance was run to predict smoking cigarettes based on individual and environmental factors. 14.1% of 206 youth reported smoking cigarettes daily, whereas 9.3% of participants reported smoking e-cigarettes occasionally. Drug use, lack of social support, deprivation, discrimination, the wait for medical gender-affirming procedures and being outside school were associated with smoking cigarettes. Contextual and individual factors should be further explored in causal analysis and taken into consideration when planning smoking prevention and cessation interventions for transgender and gender non-binary youth.

Resumo Jovens transgêneros e não-binários são particularmente vulneráveis ao tabagismo e suscetíveis a seus malefícios a saúde. Ou seja, esses grupos estão em especial risco para começar a fumar e, após o início, tendem a apresentar resultados piores quando comparados a seus pares cisgêneros. Sendo assim, o presente estudo tem como objetivo avaliar fatores associados ao uso do tabaco em jovens transgêneros e não-binários. Jovens brasileiros, com idade entre 16 e 25 anos, que se identificam como transgêneros ou não-binários responderam um questionário on-line. Uma Regressão de Poisson com variância robusta foi realizada para predizer o consumo de cigarros com base em fatores individuais e ambientais. 14,1% de 206 jovens relataram fumar cigarros diariamente, enquanto 9,3% dos participantes revelaram fumar cigarros eletrônicos ocasionalmente. Uso de drogas, falta de suporte social, experiências de privação, discriminação, espera para procedimentos médicos de afirmação de gênero e evasão escolar foram associados ao consumo de cigarros entre jovens transgêneros e não-binários brasileiros. Sendo assim, os fatores individuais e contextuais citados devem receber especial enfoque no planejamento de intervenções de prevenção e interrupção do tabagismo voltados a jovens transgêneros e não-binários brasileiros.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review.

A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review / Elementos multinivel asociados a seroclasificación por VIH en encuentros sexuales: revisión de alcance de la literatura

Abstract A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

Resumen Se desarrolló una revisión de alcance de la literatura para identificar elementos multinivel relacionados a la seroclasificación de VIH. Se incluyeron artículos de EBSCO, PubMed y Science Direct con serosort* o serosorting en título o resumen, escritos en Inglés o Español. No se aplicaron restricciones por tipo de población y diseño. Después de remover duplicados, se recuperaron 239 records, solo 181 referencias se extrajeron para revisión a texto completo. Nivel individual: Conocimiento del VIH, seroestado, percepciones de riesgo, habilidades para develar el seroestado y negociar el condón, motivaciones, uso de drogas, estigma, actitudes sobre uso del condón, y percepciones/ creencias acerca del VIH y tratamientos, tasas de infección y tamizaje de VIH, factores conductuales. Nivel interpersonal: redes sociales, habilidades (negociación de la conducta sexual, y comunicación). Nivel comunitario: Estigma, normas sociales, acceso a servicios de VIH. Nivel estructural: contexto político, políticas públicas y financiamiento relacionado al VIH. La seroclasificación de VIH no es solamente una conducta interpersonal, incluye elementos multinivel que deben ser reconocidos por los profesionales de salud y tomadores de decisiones.

Intersectionality in quantitative research: A systematic review of its emergence and applications of theory and methods.

BACKGROUND: Intersectionality is a theoretical framework rooted in the premise that human experience is jointly shaped by multiple social positions (e.g. race, gender), and cannot be adequately understood by considering social positions independently. Used widely in qualitative studies, its uptake in quantitative research has been more recent. OBJECTIVES: To characterize quantitative research applications of intersectionality from 1989 to mid-2020, to evaluate basic integration of theoretical frameworks, and to identify innovative methods that could be applied to health research. METHODS: Adhering to PRISMA guidelines, we conducted a systematic review of peer-reviewed articles indexed within Scopus, Medline, ProQuest Political Science and Public Administration, and PsycINFO. Original English-language quantitative or mixed-methods research or methods papers that explicitly applied intersectionality theoretical frameworks were included. Experimental studies on perception/stereotyping and measures development or validation studies were excluded. We extracted data related to publication, study design, quantitative methods, and application of intersectionality. RESULTS: 707 articles (671 applied studies, 25 methods-only papers, 11 methods plus application) met inclusion criteria. Articles were published in journals across a range of disciplines, most commonly psychology, sociology, and medical/life sciences; 40.8% studied a health-related outcome. Results supported concerns among intersectionality scholars that core theoretical tenets are often lost or misinterpreted in quantitative research; about one in four applied articles (26.9%) failed to define intersectionality, while one in six (17.5%) included intersectional position components not reflective of social power. Quantitative methods were simplistic (most often regression with interactions, cross-classified variables, or stratification) and were often misapplied or misinterpreted. Several novel methods were identified. CONCLUSIONS: Intersectionality is frequently misunderstood when bridging theory into quantitative methodology. Further work is required to (1) ensure researchers understand key features that define quantitative intersectionality analyses, (2) improve reporting practices for intersectional analyses, and (3) develop and adapt quantitative methods.

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review.

OBJECTIVES: To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally. DESIGN: Systematic review with narrative synthesis. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018. INCLUSION CRITERIA: Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest. RESULTS: We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use. CONCLUSIONS: Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

Identifying visible minorities or racialized persons on surveys: can we just ask?

OBJECTIVES: Visible minorities are a group categorized in health research to identify and track inequalities, or to study the impact of racialization. We compared classifications obtained from a commonly used measure (Statistics Canada standard) with those obtained by two direct questions-whether one is a member of a visible minority group and whether one is perceived or treated as a person of colour. METHODS: A mixed-methods analysis was conducted using data from an English-language online survey (n = 311) and cognitive interviews with a maximum diversity subsample (n = 79). Participants were Canadian residents age 14 and older. RESULTS: Agreement between the single visible minority item and the standard was good (Cohen's Κ = 0.725; 95% CI = 0.629, 0.820). However, participants understood "visible minority" in different and often literal ways, sometimes including those living with visible disabilities or who were visibly transgender or poor. Agreement between the single person of colour item and the standard was very good (Κ = 0.830; 95% CI = 0.747, 0.913). "Person of colour" was more clearly understood to reflect ethnoracial background and may better capture the group likely to be targeted for racism than the Statistics Canada standard. When Indigenous participants who reported being persons of colour were reclassified to reflect the government definition of visible minority as non-Indigenous, this measure had strong agreement with the current federal standard measure (K = 0.851; 95% CI = 0.772, 0.930). CONCLUSION: A single question on perception or treatment as a person of colour appears to well identify racialized persons and may alternately be recoded to approximate government classification of visible minorities.

Math versus meaning in MAIHDA: A commentary on multilevel statistical models for quantitative intersectionality.

RATIONALE: Intersectionality has been increasingly adopted as a theoretical framework within quantitative research, raising questions about the congruence between theory and statistical methodology. Which methods best map onto intersectionality theory, with regard to their assumptions and the results they produce? Which methods are best positioned to provide information on health inequalities and direction for their remediation? One method, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA), has been argued to provide statistical efficiency for high-dimensional intersectional analysis along with valid intersection-specific predictions and tests of interactions. However, the method has not been thoroughly tested in scenarios where ground truth is known. METHOD: We perform a simulation analysis using plausible data generating scenarios where intersectional effects are present. We apply variants of MAIHDA and ordinary least squares regression to each, and we observe how the effects are reflected in the estimates that the methods produce. RESULTS: The first-order fixed effects estimated by MAIHDA can be interpreted neither as effects on mean outcome when interacting variables are set to zero (as in a correctly-specified linear regression model), nor as effects on mean outcome averaged over the individuals in the population (as in a misspecified linear regression model), but rather as effects on mean outcome averaged over an artificial population where all intersections are of equal size. Furthermore, the values of the random effects do not reflect advantage or disadvantage of different intersectional groups. CONCLUSIONS: Because first-order fixed effects estimates are the reference point for interpreting random effects as intersectional effects in MAIHDA analyses, the random effects alone do not provide meaningful estimates of intersectional advantage or disadvantage. Rather, the fixed and random parts of the model must be combined for their estimates to be meaningful. We therefore advise caution when interpreting the results of MAIHDA in quantitative intersectional analyses.

Dealing with gender-related and general stress: Substance use among Brazilian transgender youth.

INTRODUCTION: Adolescent substance use is a major public health concern since it enhances adolescent morbidity and mortality, affecting adulthood health and well-being. Although current evidence shows a high risk for substance use among transgender populations, to date, few studies evaluate substance use among transgender youth. METHOD: Brazilian transgender youth (ages between 16 and 25 years old) answered an online questionnaire measuring demographics, substance use and modifiable factors associated with drug use to deal with general stress, gender-related stress, and recreational use. RESULTS: Cannabis was the most frequent substance used among transgender youth (20.88%; CI 95% 23.71-36.19), whereas 11.45% (CI 95% 11.38-21.47) of volunteers disclosed use of pain medication, such as codeine, and 5.05% (CI 95% 3.71-10.78) revealed use of sedatives and tranquilizers in the last 30 days. ADH medication (not prescribed), as well as cocaine and other drugs (such as antihistamines and Hookah), was also reported by 2.36% (CI 95% 0.92-5.84), 2.69% (CI 95% 1.24-6.49) and 4.04% (CI 95% 2.61-8.98) of transgender youth. CONCLUSION: A logistic regression model showed that discrimination and home instability were the primary determinants of vulnerable to substance use among youth. Therefore, the harm reduction strategies must affect the social and physical aspects of transgender youth lives.

HIV-related care for transgender people: A systematic review of studies from around the world.

RATIONALE: Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people. OBJECTIVE: The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people. METHOD: Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations. RESULTS: From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment. CONCLUSIONS: The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.