Valuing the Vulnerable - The Important Role of Transgender Communities in Biomedical Research.

Every cell has a genetic sex that is determined at the time of fertilization. However, the natal sex of cells may not match the hormonal environment in which they reside in transgender individuals. This discordance provides a unique opportunity to study the short- and long-term effects across a range of cellular functions, health conditions, physiologic processes and psychosocial outcomes to the benefit of transgender and cisgender communities. While there is a growing body of knowledge as the literature on sex differences in virtually every organ system accumulates, there remains a paucity of data on the effect of cross hormonal therapy on cellular function in transgender individuals. Beyond cellular function, the effect of cross hormonal therapy on neuroanatomy, the interpretation of neuropsychological assessments or even the effect of daily stressors of stigma and discrimination on long-term neurocognitive function remain unclear. In 2011 the Institute of Medicine indicated that transgender adults were an understudied population and in critical need of more biomedical and population health research, yet the experience of stigma, discrimination, microaggressions, limited access to culturally competent care continue to make this an unfulfilled mandate. In addition to using a life course perspective, it is essential to identify research gaps and formulate a responsive research agenda while maintaining scientific rigor and respectful involvement of the population under study. None of this, however, will enhance the participation of transgender communities in biomedical research until the transgender and biomedical research communities can engage in open, respectful and bidirectional dialogue. From respectful, sensitive and appropriate health care to culturally competent research engagement from study inception to data dissemination, transgender communities can make an important and valuable contribution to biomedical research. Inclusion of their voices at all levels, including investigators from transgender communities, are essential to advance this much overdue scientific agenda. Transgender, cisgender and the biomedical research communities will all benefit from a more inclusive and expansive research agenda.

Health Care Experiences of Black Transgender Women and Men Who Have Sex With Men: A Qualitative Study.

Black sexual and gender minorities (SGM) are at greater risk for HIV compared to their White, cisgender, heterosexual counterparts. Linkage to culturally sensitive health care is, therefore, pivotal for HIV prevention and treatment of Black SGM. Unfortunately, social and structural challenges undermine Black SGM individuals' abilities to obtain adequate health care services, indicating a need to understand Black SGM perceptions of health care. To address this gap, we interviewed Black men who have sex with men and transwomen about their experiences with health care providers. Participants discussed needs and concerns, including provider SGM identity diversity and education; assumptions, judgment, stigma, and discrimination; and ability to establish a personal bond, trust, and familiarity. Black SGM indicated that providers often did not meet their needs in different ways regarding their SGM identities. Findings suggest a need for provider cultural sensitivity education programs that address the needs of Black SGM in health care.

"We have a stronger survival mode": exploring knowledge gaps and culturally sensitive messaging of PrEP among Latino men who have sex with men and Latina transgender women in Los Angeles, CA.

Latino men who have sex with men (LMSM) and Latina transgender women (LTGW) often lack access to HIV prevention information and strategies such as pre-exposure prophylaxis (PrEP). We explored knowledge gaps and culturally sensitive messaging about PrEP among HIV-negative LMSM and LTGW in Los Angeles. We recruited participants from a Latinx LGBT community-based organization. We conducted nine focus groups (n = 91 participants) with 52 LMSM and 39 LTGW. We used a rapid assessment process to create narrative reports that we analyzed using thematic analysis. Key quotes were transcribed verbatim; they were reviewed by the team, then uploaded to Dedoose to identify themes across sites and between groups. Three themes emerged for both LMSM and LTGW: knowledge gaps regarding PrEP remain; people who have knowledge about PrEP often served as its champions; highlighting positive aspects of culture could help improve PreP's uptake and sustained use. Only LMSM worried that PrEP could impact condom use. Some issues were more pronounced among LTGW (e.g., more limited access to PrEP); others were unique to LTGW (e.g., worry about drug-hormones interactions). Collaborative research, programs, and policies, informed by LMSM and LTGW themselves, are needed to narrow existing knowledge gaps and promote PrEP uptake and sustained utilization.

Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006-2017.

Background. Transgender women (transwomen) in the United States have been shown to have high HIV risk with Black and Hispanic transwomen being particularly vulnerable. Growing research on transgender men (transmen) also shows increased HIV risk and burden, although not as much is known for this transgender population.Objectives. This systematic review estimates the prevalence of self-reported and laboratory-confirmed HIV infection, reported sexual and injection behaviors, and contextual factors associated with HIV risk of transgender persons living in the United States.Search Methods. We searched the HIV Prevention Research Synthesis database and MEDLINE, EMBASE, PsycINFO, CINAHL, and Sociological Abstracts databases from January 2006 to March 2017 and January 2006 to May 2017, respectively. Additional hand searches were conducted in December 2017 to obtain studies not found in the literature searches.Selection Criteria. Eligible reports were published US-based studies that included transgender persons and reported HIV status.Data collection and analysis. Data were double-coded and quality assessed. We used random-effects models employing the DerSimonian-Laird method to calculate overall prevalence of HIV infection, risk behaviors, and contextual factors for transwomen, transmen, and race/ethnicity subgroups.Main Results. We reviewed 88 studies, the majority of which were cross-sectional surveys. Overall laboratory-confirmed estimated prevalence of HIV infection was 9.2% (95% confidence interval [CI] = 6.0%, 13.7%; κ = 24). Among transwomen and transmen, HIV infection prevalence estimates were 14.1% (95% CI = 8.7%, 22.2%; κ = 13) and 3.2% (95% CI = 1.4%, 7.1%; κ = 8), respectively. Self-reported HIV infection was 16.1% (95% CI = 12.0%, 21.2%; κ = 44), 21.0% (95% CI = 15.9%, 27.2%; κ = 30), and 1.2% (95% CI = 0.4%, 3.1%; κ = 7) for overall, transwomen, and transmen, respectively. HIV infection estimates were highest among Blacks (44.2%; 95% CI = 23.2%, 67.5%; κ = 4). Overall, participation in sex work was 31.0% (95% CI = 23.9%, 39.0%; κ = 39). Transwomen (37.9%; 95% CI = 29.0%, 47.7%; κ = 29) reported higher participation in sex work than transmen (13.1%; 95% CI = 6.6%, 24.3%; κ = 10; P = .001). Most outcomes indicated high heterogeneity in the overall and subgroup analyses.Conclusions. The availability of more data allowed us to calculate estimates separately for transwomen and transmen. HIV prevalence estimates for US transwomen were lower than previous estimates, but estimates for HIV prevalence and participation in sex work were higher when compared with transmen. Evidence gaps remain for transmen and the syndemic relationship of HIV, risky behaviors, and contextual factors specific to the transgender experience.Public Health Implications. This study highlights gender disparities for HIV and risky sexual behavior, as well as evidence gaps that exist for transmen. Tailored programs and services for the transgender population need to be developed to encourage use of and access to HIV prevention services.

Viewing Time and Self-Report Measures of Sexual Attraction in Samoan Cisgender and Transgender Androphilic Males.

Across cultures, androphilic males (natal males who are predominantly sexually attracted to adult men, not women) tend to present in one of two forms: cisgender or transgender. Previous research has shown that, although their gender presentation and identities are distinct, the two forms are similar in many other ways. The present study examined whether cisgender and transgender androphilic males exhibit a similar pattern of self-reported sexual attraction and viewing time response to images of men and women, and one that is directly inverse to that of cisgender gynephilic males (natal males who are predominately sexually attracted to adult women, not men). Using measures of self-reported sexual attraction and viewing time, we compared the response patterns of Samoan cisgender males who self-identified as men, were predominantly attracted to men, and had sex only with men (N = 16) and Samoan transgender males who self-identified as fa'afafine, were predominantly attracted to men, and had sex only with men (N = 30). Samoan cisgender males who self-identified as men, were predominantly attracted to women, and had sex only with women (N = 31) served as a comparison group. Androphilic men and fa'afafine reported greater sexual attraction to men than women and viewed the images of men longer than those of women. Gynephilic men showed the inverse pattern. Viewing time discrepancies between participant's preferred gender and their non-preferred gender were greater for gynephilic men compared to the two androphilic groups. The implications of these preliminary findings for the use of viewing time measures of male sexual orientation across different cultural contexts are discussed.

A comparison of HIV-risk behaviors between young black cisgender men who have sex with men and young black transgender women who have sex with men.

This study compared sexually transmitted infection (STI)-associated risks between young Black cisgender men who have sex with men (YBMSM) and young Black transwomen who have sex with men (YBTWSM). Comparisons pertained to: (1) prevalence of infections; (2) sexual risk; (3) partner-related risks; and (4) socioeconomic marginalization. YBMSM (n = 577) and YBTWSM (n = 32) were recruited from an STI clinic in the USA. Volunteers completed a computer-assisted self-interview and medical records were abstracted for STI/HIV information. Significantly greater prevalence of pharyngeal Chlamydia ( P < .001) and pharyngeal gonorrhea ( P = .04) occurred among YBTWSM; however, both associations were moderated and only significant for HIV-uninfected volunteers. YBTWSM had more oral sex partners and more frequent engagement in oral sex. The number of new sex partners for anal receptive sex was greater in YBTWSM. YBTWSM were more likely to exchange sex for money/drugs ( P < .001), have sex with men recently in prison ( P < .001), who were "anonymous" ( P = .004), or who were "one night stands" ( P < .001). YBTWSM were more likely to depend on sex partners for money food, etc. ( P < .001), to miss meals due to lack of money ( P = .01), and to report having ever being incarcerated ( P = .009). Compared to cisgender YBMSM, YBTWSM experience multiple risk factors relative to the acquisition/transmission of STIs and HIV.

Ethnicity, Sex Work, and Incident HIV/STI Among Transgender Women in New York City: A Three Year Prospective Study.

In conjunction with a 3-year prospective study of 199 transgender women from the New York City Area, we attempted to better understand why non-Whites are much more likely than Whites to become HIV infected. We first assessed associations of ethnicity with sex work, sexual risk behavior for HIV, and biologically-determined HIV/STI, and then assessed the extent to which these ethnic differences are explained by socioeconomic factors, immigration status, and sexual orientation. Statistical techniques included generalized estimating equations and Cox proportional hazards. As expected, compared to Whites, Blacks and Hispanics were more involved in the sex trade, more likely to report unprotected receptive anal intercourse, and as a result, more likely to become HIV/STI infected. All of these associations were mediated by androphilia, and to a lesser extent androphilia/gynephilia. Sexual orientation is a significant but little recognized factors associated with new cases of HIV/STI among transgender women of color.

Examining the Sociocultural Context of HIV-related Risk Behaviors Among Kathoey (Male-to-female Transgender Women) Sex Workers in Bangkok, Thailand.

Kathoey (male-to-female transgender) sex workers (KSW) in Thailand are at high risk for sexually transmitted infections; however, few qualitative studies have been conducted to understand the sociocultural context of engaging in HIV risk behaviors. A total of 24 participants were purposively sampled in Bangkok based on KSW work venues and substance use. Results revealed the importance of participants' understanding of the self in relation to establishing economic independence through sex work, which could then be used to re-establish support from family, who often have not accepted a son's gender transition. Participants linked being kathoey to a belief in fate but did not view engagement in sex work in the same way. Different sex work venues exposed KSW to different risky situations. HIV prevention programs for kathoey must address the importance of economic security and its relation to social support and gender transition within a cultural- and work-environment-specific framework.

Challenging cisgenderism in the ageing and aged care sector: Meeting the needs of older people of trans and/or non-binary experience.

Recent Australian legislative and policy changes can benefit people of trans and/or non-binary experience (e.g. men assigned female with stereotypically 'female' bodies, women assigned male with stereotypically 'male' bodies, and people who identify as genderqueer, agender [having no gender], bi-gender [having two genders] or another gender option). These populations often experience cisgenderism, which previous research defined as 'the ideology that invalidates people's own understanding of their genders and bodies'. Some documented forms of cisgenderism include pathologising (treating people's genders and bodies as disordered) and misgendering (disregarding people's own understanding and classifications of their genders and bodies). This system of classifying people's lived experiences of gender and body invalidation is called the cisgenderism framework. Applying the cisgenderism framework in the ageing and aged care sector can enhance service providers' ability to meet the needs of older people of trans and/or non-binary experience.

It is more than sex and clothes: Culturally safe services for older lesbian, gay, bisexual, transgender and intersex people.

This paper outlines the development of culturally safe services for older lesbian, gay, bisexual, transgender and intersex people. It draws on a framework for cultural safety, developed in New Zealand which incorporates an understanding of how history, culture and power imbalances influence the relationship between service providers and Maori people. This has been adapted to the needs of older lesbian, gay, bisexual, transgender and intersex Australians.

Understanding the experiences and needs of lesbian, gay, bisexual and trans Australians living with dementia, and their partners.

AIM: To outline the experiences and needs of lesbian, gay, bisexual and trans (LGBT) Australians living with dementia - and their partners. METHODS: In-depth interviews were conducted with LGBT people, their partners and service providers. RESULTS: LGBT people living with dementia experience unique challenges including the failure of some families of origin and service providers to understand and value their sexual orientation or gender identity. The fear of discrimination by service providers results in greater reliance on intimate partners for care and compounds social isolation. CONCLUSIONS: The unique experiences of LGBT people with dementia are not well understood. There is a need to recognise historical experiences, including familial relationships, and provide advocacy to ensure sexual and gender rights are not violated. There is also a need to ensure that the experiences and perspectives of LGBT people living with dementia inform the development of services.

"Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorias sexuales en México / "Many deaths could be avoided": discrimination, stigma and gender violence against non-heterosexual men: the Mexican situation / "Poderiam ser evitadas muitas 'mortas'": discriminação, estigma e violência contra as minorias sexuais no México

A partir del análisis de la información recabada en diagnósticos participativos comunitarios realizados en 2011, este artículo describe formas, actores, lugares de discriminación y estigma padecidos en varias regiones metropolitanas de México por personas transexuales, travestis, gays y bisexuales, así como personas infectadas por el VIH. Se muestra cómo la violencia hacia dichas poblaciones es ejercida, reproducida y legitimada desde instituciones públicas, e interiorizadas por las propias minorías sexuales. Según se argumenta, la discriminación institucionalizada, la interiorización del estigma y la desinformación en relación a la salud sexual y prevención de VIH, conllevan una vulneración en términos de salud, acceso a servicios de justicia y defensa de derechos humanos. También favorecen una mayor segregación urbana y legitiman indirectamente el statu-quo social en el espacio urbano.

By presenting the results of participative community group evaluations held recently, this paper describes the forms, actors, and sites of discrimination and stigma affecting transsexuals, travesties, gays, bisexuals, and HIV-positives persons in various metropolitan regions of Mexico. It shows how the violence against those populations is reproduced and legitimated by public institutions. It argues that this institutionalized discrimination, together with the individual reproduction of stigma, and misinformation regarding sexual health and prevention; result in a dramatic degree of vulnerability for this populations, in terms of health and access to Human Rights defense, security, and legal services. Furthermore, those conditions also favor urban segregation and, indirectly, legitimize the social status quo in urban space.

A partir da análise da informação obtida em diagnósticos participativos comunitários realizados recentemente, este artigo descreve as formas, os atores, os lugares de discriminação e estigma sofridos em várias regiões metropolitanas do México por pessoas transexuais, travestis, gays e bissexuais, assim como por pessoas infectadas pelo HIV. Mostra-se como a violência contra tais populações é exercida, reproduzida e legitimada pelas instituições públicas, e interiorizadas pelas próprias minorias sexuais. Conforme se argumenta, a discriminação institucionalizada, a interiorização do estigma e a desinformação em relação à saúde sexual e à prevenção do HIV implicam a vulnerabilidade de tais populações em termos de saúde e acesso a serviços de justiça e defesa de direitos humanos. Também favorecem uma maior segregação urbana e legitimam indiretamente o status-quo social no espaço urbano.

Pigmentocracia dei deseo en el mercado sexual Trans de Cali, Colombia / Pigmentocracy of desire in the trans sexual market in Cali, Colombia / Pigmentocracia do desejo no mercado sexual Trans de Cali, Colômbia

Este artículo analiza el efecto de la condición étnico/racial para las mujeres negras Trans en el mercado sexual Trans femenino en Cali, Colombia. Se trata de un estudio sobre el trabajo sexual desde una perspectiva interseccional, a través de los aportes del black feminism, articulando raza como color de piel, auto-identidad de sexo/género, clase social y grupo etario, en la producción y consumo de servicios sexuales ofrecidos por mujeres no biológicas, que realizan en determinados casos el trabajo de peluquería. La hipótesis indica, como efecto más importante que el "exotismo de los cuerpos negros", en el juego de los capitales eróticos, valoriza sobremanera las "mujeres masculinas" o "activas" dotadas con "pene potente". Ello, debido a la confluencia entre clientes cuya fantasia sexual se recrea en una mujer fálica, y hombres biológicos, jóvenes de clases populares, en su mayoría negros, que reconstruyen sus identidades de sexo/género y encuentran en el mercado sexual un espacio laboral.

This article analyzes the effect of black trans women's ethnic/racial condition in the female trans sex market in the city of Cali, Colombia. The study looked at sex work from an intersectional perspective, with the contributions of Black Feminism, articulating race as skin color, sex/gender self-identity, social class and age group in the production and consumption of sex services offered by not-biologically-born women who sometimes work as hairdressers. We argue that the "exoticism of black bodies" as erotic capital gives a high value to the "wellendowed male" or "active" black woman with a "potent penis", in the confluence of clients whose sexual fantasy valorizes a phallic woman, and lower class male-born black youths who reconstruct their sex/gender identities and find a labor niche in the sex market.

Este artigo analisa o efeito da condição étnico/racial para as mulheres negras trans no mercado sexual trans feminino em Cali, Colômbia. Trata-se de um estudo sobre o trabalho sexual a partir de uma perspectiva interseccional, através das contribuições do black feminism, articulando raça como cor de pele, autoidentidade de sexo/gênero, classe social e grupo etário na produção e no consumo de serviços sexuais oferecidos por mulheres não biológicas, que realizam, em determinados casos, o trabalho de cabeleireiras. A hipótese indica que o "exotismo dos corpos negros", no jogo dos capitais eróticos, valoriza sobremaneira as "mulheres masculinas" ou "ativas" dotadas de "pênis potente". Isto devido à convergência entre clientes cuja fantasia sexual se recria em uma mulher fálica e em homens biológicos, jovens de classes populares, em sua maioria negros, que reconstroem suas identidades de sexo/ gênero e encontram no mercado sexual um espaço de trabalho.

Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school.

PURPOSE: To estimate the size and demographic characteristics of the lesbian, gay, bisexual, and transgender youth populations using data from the 2011 Youth Risk Behavior Survey (YRBS) administered in San Francisco Unified School District middle schools. METHODS: The YRBS was administered to a stratified random sample of 2,730 youth (grades 6-8) across all 22 public middle schools in San Francisco. Cross-tabulations using complex samples analyses were used to derive population estimates and confidence intervals. RESULTS AND CONCLUSIONS: Results show that 3.8% of middle school students identify as lesbian, gay, or bisexual, and 1.3% of middle school students identify as transgender. To improve our understanding of the size of these populations across the nation, researchers conclude it is imperative that all YRBS administration sites include items on sexual orientation and gender identity as they would any other demographic item, such as race/ethnicity, sex, or age. The current lack of reliable data on the size and characteristics of the lesbian, gay, bisexual, and transgender youth population limits the capacity of policy makers, administrators, and practitioners to address their needs.

Perceived discrimination and depression among low-income Latina male-to-female transgender women.

BACKGROUND: This study examines exposure to perceived discrimination and its association with depression among low-income, Latina male-to-female transgender women as well as evaluates the impact of sexual partner violence and mistreatment on depression. METHODS: A total of 220 Latina male-to-female transgender women who resided in Los Angeles, California, were recruited through community based organizations and referrals. Participants completed individual interviews using a structured questionnaire. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Perceived discrimination was assessed using a fifteen-item measure that was designed to assess the experiences of maltreatment of transgender individuals. Multinomial logistic regression was used to examine the association between perceived discrimination and depression after controlling for the presence of other variables. RESULTS: Of the sample, 35% reported significant depressive symptoms (PHQ-9 ≥ 15). Additionally, one-third of the participants indicated that in the two weeks prior to the interviews they had thought either of hurting themselves or that they would be better off dead. The extent of perceived discrimination in this population was extensive. Many of the participants experienced discrimination on a daily basis (14%) or at least once or twice a week (25%) as demonstrated by a positive response to at least 7 of 15 items in the measure of perceived discrimination. Almost six out of ten participants admitted that they had been victims of sexual partner violence. Those who reported more frequent discrimination were more likely to be identified with severe depression. There was also a notable association between self-reported history of sexual partner violence and depression severity. CONCLUSIONS: A significant association between depression severity and perceived discrimination was identified. How exposure to discrimination leads to increased risk of mental health problems needs additional investigation. Models investigating the association between perceived discrimination and depression among transgender women should include sexual partner violence as a potential confounding variable.