Healthcare stereotype threat, healthcare access, and health outcomes in a probability sample of U.S. transgender and gender diverse adults.

Background: Health inequities among transgender and gender diverse (TGD) populations are well-documented and may be partially explained by the complex social power dynamics that lead to stigmatization. Healthcare Stereotype Threat (HCST) refers to the fear and threat of being perceived negatively based on identity-related stereotypes and may influence health and healthcare experiences. Few studies have investigated associations of HCST with healthcare access and health outcomes for TGD individuals. Methods: We analyzed the U.S. Transgender Population Health Survey, a cross-sectional national probability sample of 274 TGD adults recruited April 2016-December 2018. Participants self-reported HCST through a 4-item scale. We estimated prevalence ratios (PR) for the association between HCST and binary healthcare access indicators and health outcomes using Poisson models with robust variance. Prevalence ratios (PR) were estimated using negative binomial models for the association between HCST and number of past-month poor physical and mental health days. Models adjusted for sociodemographics and medical gender affirmation. Results: The mean age was 34.2 years; 30.9 % identified as transgender men, 37.8 % transgender women, and 31.3 % genderqueer/nonbinary. HCST threat was associated with increased prevalence of not having a personal doctor/healthcare provider (PR = 1.25; 95 %CI = 1.00-1.56) and reporting fair/poor general health vs good/very good/excellent health (PR = 1.92; 95 %CI = 1.37-2.70). Higher HCST was also associated with more frequent past-month poor physical (PR = 1.34; 95 %CI = 1.12-1.59) and mental (PR = 1.49; 95 %CI = 1.33-1.66) health days. Conclusion: HCST may contribute to adverse healthcare access and health outcomes in TGD populations, though prospective studies are needed. Multilevel interventions are recommended to create safe, gender-affirming healthcare environments that mitigate HCST.

Trajectories of Mental Distress Among US Women by Sexual Orientation and Racialized Group During the First Year of the COVID-19 Pandemic.

Objectives. To describe longitudinal trends in the prevalence of mental distress across the first year of the COVID-19 pandemic (April 2020‒April 2021) among US women at the intersection of sexual orientation and racialized group. Methods. Participants included 49 805 cisgender women and female-identified people from the COVID-19 Sub-Study, a cohort of US adults embedded within the Nurses' Health Studies 2 and 3 and the Growing Up Today Study. We fit generalized estimating equation Poisson models to estimate trends in depressive and anxiety symptoms by sexual orientation (gay or lesbian, bisexual, mostly heterosexual, completely heterosexual); subsequent models explored further differences by racialized group (Asian, Black, Latine, White, other or unlisted). Results. Relative to completely heterosexual peers, gay or lesbian, bisexual, and mostly heterosexual women had a higher prevalence of depressive and anxiety symptoms at each study wave and experienced widening inequities over time. Inequities were largest for sexual minority women of color, although confidence intervals were wide. Conclusions. The COVID-19 pandemic may have exacerbated already-glaring mental health inequities affecting sexual minority women, especially those belonging to marginalized racialized groups. Future research should investigate structural drivers of these patterns to inform policy-oriented interventions. (Am J Public Health. 2024;114(5):511-522. https://doi.org/10.2105/AJPH.2024.307601).

Health status of transgender people globally: A systematic review of research on disease burden and correlates.

BACKGROUND AND OBJECTIVES: Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality. DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS: We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis. RESULTS: The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality. CONCLUSIONS AND IMPLICATIONS: Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants. REGISTRATION: PROSPERO CRD42021234043.

Food Insecurity Is High in a Multi-Site Cohort of Transgender Women Vulnerable to or Living with HIV in the Eastern and Southern United States: Baseline Findings from the LITE Cohort.

The prevalence and correlates of food insecurity-the unavailability of food and limited access to it-have not been adequately considered among transgender women (TW), particularly alongside other health-related conditions burdening this population, such as HIV infection. This study examined the prevalence and correlates of food insecurity among TW. Between 2018 and 2020, 1590 TW in the Eastern and Southern U.S. completed a multi-site baseline assessment (socio-behavioral survey and HIV testing). Descriptive statistics were calculated and multivariable Poisson models with robust error variance were used to estimate prevalence ratios and 95% confidence intervals for correlates of food insecurity (dichotomized as sometimes-to-always vs. seldom-to-never running out of food). Eighteen percent of TW were living with HIV and nearly half of participants (44%) reported food insecurity. Correlates of food insecurity included being Black, multiracial, or another race/ethnicity; having < college education, low income, unstable housing, and high anticipated discrimination; and a history of sex work and sexual violence (all p < 0.05). Food insecurity was highly prevalent among TW. Current programs to provide food support do not adequately meet the needs of TW. HIV pr evention and care programs may benefit from addressing food insecurity.

Structural Racism-Related State Laws and Healthcare Access Among Black, Latine, and White U.S. Adults.

Racialized healthcare inequities in the USA remain glaring, yet root causes are understudied. To address this gap, we created a state-level structural racism legal index (SRLI) using the Structural Racism-Related State Law Database and analyzed its association with racialized inequities in four outcomes (lacking health insurance coverage, lacking a personal doctor, avoiding care due to cost, lacking a routine check-up) from the 2013 Behavioral Risk Factor Surveillance System (N = 454,834). To obtain predicted probabilities by SRLI quartiles (Q1 = less structural racism, Q4 = more structural racism) and racialized group, we fit survey-weighted multilevel logistic models adjusted for individual- and state-level covariates. We found substantial healthcare access inequities across racialized groups within SRLI quartiles and less pronounced, but still meaningful, inequities within racialized groups across SRLI quartiles. For example, the predicted probabilities of lacking health insurance coverage across SRLI quartiles ranged from 13 to 20% among Black adults, 31 to 41% among Latine adults, and 8 to 11% among White adults. Across racialized groups in Q4 states, predicted probabilities ranged from 11% among White adults to 41% among Latine adults. Similar patterns were observed for lacking a personal doctor and avoiding care due to cost. Findings underscore the need to address structural racism in laws and policies to mitigate these inequities.

Quantitative approaches to measuring structural cisgenderism.

There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.

Legislating Inequity: Structural Racism In Groups Of State Laws And Associations With Premature Mortality Rates.

Most evaluations of health equity policy have focused on the effects of individual laws. However, multiple laws' combined effects better reflect the crosscutting nature of structurally racist legal regimes. To measure the combined effects of multiple laws, we used latent class analysis, a method for detecting unobserved "subgroups" in a population, to identify clusters of US states based on thirteen structural racism-related legal domains in 2013. We identified three classes of states: one with predominantly harmful laws ([Formula: see text]), another with predominantly protective laws ([Formula: see text]), and a third with a mix of both ([Formula: see text]). Premature mortality rates overall-defined as deaths before age seventy-five per 100,000 population-were highest in states with predominantly harmful laws, which included eighteen states with past Jim Crow laws. This study offers a new method for measuring structural racism on the basis of how groups of laws are associated with premature mortality rates.

Associations between sexual orientation, sex education curriculum, and exposure to affirming/disaffirming LGB content in two US-based cohorts of adolescents.

Sexual health education experienced by lesbian, gay, and bisexual (LGB) youth varies widely in relevancy and representation. However, associations among sexual orientation, type of sex education, and exposure to affirming or disaffirming content have yet to be examined. Understanding these patterns can help to address gaps in LGB-sensitive sex education. Our goal in this study was to examine the prevalence and associations among abstinence-only until marriage (AOUM) and comprehensive sex education with LGB-affirming and -disaffirming content sought/received before age 18 (from 1999-2014) by sexual orientation (completely heterosexual with same-sex contact, completely heterosexual with no same-sex contact, mostly heterosexual, bisexual, gay/lesbian) in a sample of 12,876 US young adults from the Growing Up Today Study. Compared to completely heterosexual referents, LGB participants who received AOUM sex education were more likely to encounter LGB-disaffirming content, and this effect was largest among sexual minority participants. Conversely, exposure to comprehensive sex education was associated with receipt of LGB-affirming information. Overall, participants commonly reported receiving AOUM sex education, which may lead to deficits and potential harm to sexual minorities.

Egg donor self-reports of ovarian hyperstimulation syndrome: severity by trigger type, oocytes retrieved, and prior history.

PURPOSE: To evaluate self-reported survey data provided by US oocyte donors on their experiences with ovarian hyperstimulation syndrome and possible correlations between OHSS severity and number of oocytes retrieved, trigger type, and prior OHSS history. METHODS: An 85-question retrospective survey was administered online. Survey questions included demographic information, reasons for donating, immediate per-cycle experiences and outcomes, perceptions of informed consent, and perceived impact of donation on long-term health. Quantitative Data for this study was collected between February 2019 and September 2020 via QualtricsXM (January 2019), an online survey platform. Follow-up interviews were also conducted. Participants were recruited via fertility clinics, egg donation agencies, and online forum. The research was approved by the University of California, San Francisco Institutional Review Board (#14-14765). RESULTS: Of 420 initiated US oocyte donor online surveys, 289 (68%) respondents provided detailed information on per cycle experiences with ovarian hyperstimulation syndrome, number of oocytes retrieved, and trigger type over a total of 801 cycles. On cycles where donors reported receiving GnRH agonist triggers (n = 337), they reported milder OHSS compared to cycles with hCG or dual triggers. Among donors undergoing multiple retrieval cycles, the severity of OHSS in second cycles was strongly associated with OHSS severity in first cycles. CONCLUSION: Self-reported OHSS in oocyte donors is lower in GnRH antagonist stimulation protocols combined with GnRHa trigger and in cycles where donors reported fewer than 30 oocytes retrieved. Donors who reported severe OHSS on a prior cycle were significantly more likely to experience severe OHSS on a subsequent cycle.

Racial/Ethnic Differences in Sexually Transmitted Infection Testing Among Transgender Men and Nonbinary Assigned Female at Birth Young Adults in the United States: a National Study.

BACKGROUND: Sexually transmitted infections (STIs) cause a major burden of disease in the United States (US)-especially among structurally marginalized populations, including transgender and nonbinary people, individuals assigned female at birth (AFAB), Black and Latinx/e individuals, and young adults. Although screening can help detect and prevent STIs, research on STI testing among populations at diverse intersections of multiple forms of structural marginalization, including Black, Latinx/e, and other racially/ethnically minoritized transgender men and nonbinary AFAB US young adults, is extremely scarce. METHODS: We conducted a national cross-sectional online survey of transgender and nonbinary US young adults from February to July 2019. Using Poisson regression, we estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the associations between race/ethnicity-which we conceptualized as a system of structural inequality that shapes individuals' and groups' exposure to racism-and lifetime and past-year STI testing among transgender men and nonbinary AFAB US young adults aged 18-30 years with at least one-lifetime sexual partner (N = 378). RESULTS: Approximately 74% of participants had received an STI test in their lifetime, and, among those, 72% with a past-year sexual partner had been tested for an STI in the last 12 months. We observed no statistically significant association between race/ethnicity and lifetime STI testing among transgender and nonbinary AFAB young adults with a lifetime sexual partner. In contrast, Black (PR = 1.32; 95%: 1.03, 1.68) and Latinx/e (PR = 1.39; 95% CI: 1.11, 1.75) transgender men and nonbinary AFAB young adults who ever received an STI test and had a past-year sexual partner were significantly more likely to have received an STI test in the last 12 months relative to their White counterparts, adjusting for demographic factors. Further adjustment for lifetime STI diagnosis and health insurance status did not appreciably attenuate these observed adjusted differences; however, the adjusted difference in the prevalence of past-year STI testing between Black (but not Latinx/e) and White transgender men and nonbinary AFAB young adults was no longer statistically significant upon further adjustment for educational attainment and employment status, possibly due to small sample sizes. CONCLUSION: The higher adjusted prevalence of past-year STI testing among Black and Latinx/e compared to White transgender men and nonbinary AFAB US young adults may reflect racist and xenophobic sexual stereotypes about Black and Latinx/e people among health care providers and institutions, the history of hyper-surveillance of Black and Latinx/e people by public health institutions in the context of infectious disease containment, and/or agency and resistance among Black and Latinx/e transgender men and nonbinary AFAB young adults with regard to sexual health promotion in the face of multiple compounding systems of oppression.

Experiences of and resistance to multiple discrimination in health care settings among transmasculine people of color.

BACKGROUND: Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited. METHODS: Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience-and resist-multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18-25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes. RESULTS: Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination-both independently and simultaneously-in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. DISCUSSION: Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups.

Human papillomavirus vaccination disparities among U.S. college students: An intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA).

We investigated how gender identity, sexual orientation, and race/ethnicity intersect to shape the social epidemiology of HPV vaccination initiation among U.S. college students. Cross-sectional survey data were from the National College Health Assessment (Fall, 2019-Spring, 2020; N = 65,047). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy by nesting participants within 36 social strata defined using gender identity, sexual orientation, and race/ethnicity. Bayesian multilevel logistic regression models with random intercepts for social strata were fit for HPV vaccination initiation. Intersectional models adjusted for the additive main effects to isolate intersectional interactions, controlling for age and geographic region. Social strata that included cisgender men, transgender women, and non-binary assigned-male-at-birth individuals and strata that included racial/ethnic minorities had a significantly lower likelihood of HPV vaccination initiation relative to strata including cisgender women and non-Hispanic White individuals, respectively, while strata including lesbian/gay and bisexual/pansexual/queer individuals had a significantly higher likelihood of HPV vaccination initiation relative to strata including heterosexual individuals. We also observed substantial between-stratum inequities in the predicted prevalence of HPV vaccination initiation, with estimates ranging from 59.2% for heterosexual, racial/ethnic minority, cisgender men to 87.1% for bisexual/pansexual/queer, racial/ethnic minority, non-binary assigned-female-at-birth individuals. That being said, the majority of the observed between-stratum variance was driven by additive rather than intersectional interaction effects and the discriminatory accuracy of intersectional stratification with respect to predicting HPV vaccination initiation was low. Collectively, our findings point to a need for more universal guidelines and clinician recommendations that promote HPV vaccine uptake for all adolescents, regardless of race/ethnicity, gender identity, sex-assigned-at-birth, or sexual orientation; however, utilizing an intersectional lens will ensure that resulting public health interventions address inequities and center the needs and experiences of multiply marginalized adolescents.

"Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States.

Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.