Prevalence and associated risk factors of HIV infections in a representative transgender and non-binary population in Flanders and Brussels (Belgium): Protocol for a community-based, cross-sectional study using time-location sampling.

INTRODUCTION: HIV prevalence and sexual risk have been estimated very high for transgender people. However, the limited sampling and data collection methods used in current research on transgender people potentially led to overrepresentation and generalisation of people at risk for HIV. Current HIV prevalence estimates in transgender populations are generalised from studies mainly focusing on transgender women engaging in sex work. Moreover, studies focusing on non-binary people, who identify with a broad range of identities beyond the traditional male and female gender identities, are scarce. OBJECTIVES: To estimate the HIV prevalence rate in the Flemish and Brussels (Belgium) transgender population, including transgender women, transgender men and non-binary people, and to identify the associated risk factors. METHODS: In this community-based cross-sectional study, self-identified transgender and non-binary (TGNB) people will be recruited through a two-stage time-location sampling approach. First, community settings in which TGNB people gather will be mapped to develop an accurate sampling frame. Secondly, a multistage sampling design is applied involving a stratification based on setting type (healthcare facilities vs outreach events), a selection of clusters by systematic sampling and a simple random selection of TGNB people within each cluster. Participants will complete an electronic self-reported survey to measure sociological, sexual and drug-using behaviors (risk factors) and oral fluid aliquots will be collected and tested for HIV antibodies. Logistic regression models will be used to evaluate risk factors independently associated with HIV infection. The presented study is registered at ClinicalTrials.gov (NCT04930614). DISCUSSION: This study will be the first to investigate the HIV prevalence rates and associated risk behaviors in an accurate representation of the TGNB population in a Western European country. The findings will globally serve as a knowledge base for identifying subgroups at risk for becoming infected with HIV within TGNB people and to set up targeted prevention programs.

Parental desire and fertility preservation in assigned male at birth transgender people living in Belgium.

Introduction: Transgender people who chose to proceed with gender affirming hormonal and/or surgical therapy, may face reduced options for fulfilling their parental desire in the future. The ideas and concerns of adult transgender people regarding fertility preservation and parental desire have never been reported in a large, non-clinical sample of assigned male at birth (AMAB) transgender people. Methods: A web-based survey on fertility and parenthood in (binary and non-binary) transgender people was conducted in Belgium. AMAB people were selected for this analysis. Results: We included 254 AMAB persons, of which 196 (77.2%) self-identified as transgender women (TW), 14 (5.5%) as cross-dressers and 44 (17.3%) as gender non-binary (GNB) people. Fifty-five (21.6%) respondents had a current/future parental desire, parental desire was already fulfilled in 81 (31.9%) and not present in 57 people (22.4%) (other: 19.2%). TW were more likely to express a parental desire, compared to GNB people and cross-dressers (P = 0.004). In total, 196 AMAB people previously sought medical assistance, of which 30 (15.3%) considered the loss of fertility due to the transitioning process undesirable. The majority (68.2%) did not want fertility preservation (FP). Fourteen people (9.8%) had proceeded with FP. The main reasons not to proceed with FP included not feeling the need (70; 68.0%), not desiring a genetic link with (future) child(ren) (20; 19.4%) and having to postpone hormone treatment (15; 14.6%). TW were more likely to have a parental desire and to have cryopreserved or to consider cryopreserving gametes, compared to GNB people. Conclusion: Parental desire and FP use were lower in the current non-clinical sample than in previous research on clinical samples. This can possibly be explained by the barriers transgender people face when considering fertility options, including postponing hormone therapy. Also, GNB persons have different needs for gender affirming treatment and FP.

Parental desire and fertility preservation in assigned female at birth transgender people living in Belgium.

OBJECTIVE: To study the considerations and concerns of transgender people regarding fertility preservation and parental desire in a large, nonclinical sample. Gender-affirming care can reduce fertility. Previous research on fertility in transgender people (mainly focused on people visiting health care professionals) shows low fertility preservation use. DESIGN: A web-based survey on fertility and parenthood. SETTING: Not applicable. PATIENT(S): Transgender people assigned female at birth (AFAB) were selected for this analysis (n = 172 or 40.4% of the total sample) of which 116 (67.4%) self-identified as transgender men (TM) and 56 (32.6%) as gender nonbinary (GNB) people. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Data on parental desire and fertility preservation were assessed in a large, nonclinical sample of AFAB transgender people. RESULT(S): Sixty-seven (39.0%) respondents had a current/future parental desire. Parental desire rates did not differ between TM and GNB persons. Barriers for fulfilling the parental desire (multiple response) included assumed difficulties in the adoption procedure (41.3%), fear of discrimination against the child (38.0%) or being discriminated against as a transgender parent (32.6%), and the cost for using personal genetic material (32.6%). Nine percent had cryopreserved reproductive cells or tissue. CONCLUSION(S): Even though parental desire rates in this cohort are in line with earlier research, fertility preservation use was lower in the current study. These numbers reflect the barriers transgender people face when considering fertility options, including cost and the need to postpone hormone therapy. In addition, GNB persons have different needs for gender-affirming treatment and subsequently for fertility preservation.

Health considerations for transgender women and remaining unknowns: a narrative review.

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

Effects of Gender-Affirming Hormones on Lipid, Metabolic, and Cardiac Surrogate Blood Markers in Transgender Persons.

BACKGROUND: Gender-affirming hormonal therapy consists of testosterone in transgender men and estrogens and antiandrogens in transgender women. Research has concluded that gender-affirming therapy generally leads to high satisfaction rates, increased quality of life, and higher psychological well-being. However, given the higher incidence of cardiometabolic morbidity and mortality in cisgender men compared with cisgender women, concerns about the cardiometabolic risk of androgen therapy have been raised. CONTENT: A literature research was conducted on PubMed, Embase, and Scopus, searching for relevant articles on the effects of gender-affirming hormone therapy on cardiometabolic risk and thrombosis. After screening 734 abstracts, 77 full text articles were retained, of which 11 were review articles. SUMMARY: Studies describing a higher risk for cardiometabolic and thromboembolic morbidity and/or mortality in transgender women (but not transgender men) mainly covered data on transgender women using the now obsolete ethinyl estradiol and, therefore, are no longer valid. Currently, most of the available literature on transgender people adhering to standard treatment regimens consists of retrospective cohort studies of insufficient follow-up duration. When assessing markers of cardiometabolic disease, the available literature is inconclusive, which may be ascribed to relatively short follow-up duration and small sample size. The importance of ongoing large-scale prospective studies/registries and of optimal management of conventional risk factors cannot be overemphasized.

Sexual health, transition-related risk behavior and need for health care among transgender sex workers.

Background: Research has shown that sexual risk behavior, as well as transition-related risk behavior, such as uncontrolled hormone use, auto-medication, and silicone injections, may lead to several adverse health outcomes for transgender persons. Transgender sex workers are a vulnerable group within the transgender population, who are at increased risk for these health risk behaviors. However, European research into this topic and risk population remains largely absent. Aim: This study explores the prevalence of uncontrolled gender-affirming hormone use, silicone injections, and inconsistent condom use among transgender sex workers working in Antwerp, Belgium. Methods: A descriptive analysis of a survey sample of 46 transgender sex workers, supplemented with nine in-depth interviews with transgender sex workers. Results: This population of transgender sex workers has specific socio-demographic characteristics: they are all assigned male at birth, 83% identifies as female and 76% is from Latin-American descent, mainly from Ecuador. Transition-related and sexual risk behaviors are prevalent. Current uncontrolled hormone use rate is 32%, which should be seen in light of their work as well as their migration status. Inconsistent condom use with clients is reported by 33% of the sample. Of all participants, 65% has silicone injections in one or more parts of the body, and 43% of them cites health problems due to these injections. Conclusion: The specific characteristics of this largely invisible but highly vulnerable population should be taken in account when addressing this population's health risk behavior. Access to health care and social services should be ensured, and culturally tailored health interventions that take into account their social context as well as their gender identity should be developed.