Cruel and Unusual: Reforming Carceral Systems to Protect and Affirm Transgender and Gender-Diverse Communities.

Transgender and gender-diverse communities are disproportionately incarcerated in the USA. Incarcerated gender minority populations are detained within carceral systems constructed around a cisgender (gender identity matches sex assigned at birth) binary (only male and female identities recognized) understanding of gender. This leads to marginalizing experiences while perpetuating the extreme vulnerability individuals experience in the community. In order to address this cruel and unusual experience, carceral systems should undergo "whole-setting" reforms to protect and affirm transgender and gender-diverse populations. This includes ensuring access to gender-affirming clinical care that aligns with community health standards recommended by medical professional associations. Implementing gender-affirming reforms reduces security issues and will likely improve health outcomes providing mutual benefit for both correctional staff and gender minority populations. Given the current divisive political and social environment for gender minority populations in the USA, evidence-based person-centered reforms in corrections are needed now more than ever.

Factors associated with transmasculine adults recently engaging in sexual behavior with partners of unknown STI and HIV status.

The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.

Designing a Transgender Health Training for Correctional Health Care Providers: A Feasibility Study.

Limited provider knowledge on transgender health contributes to stigmatizing interactions and access-to-care challenges for incarcerated transgender people. Drawing on interviews with recently incarcerated transgender individuals and correctional staff, we developed and piloted a transgender health training for correctional healthcare providers. Providers indicated that the training provided them with the requisite competencies to provide gender-affirming care to transgender patients. Participants also found the intervention to be highly acceptable and feasible and recommended that the training be provided to others. Additionally, results suggested that the training may be able to increase providers' transgender-related knowledge. Further testing of the intervention is warranted.

Sensitive Health Topics With Underserved Patient Populations: Methodological Considerations for Online Focus Group Discussions.

Online focus group discussions provide an anonymous environment to assess sensitive, health-related experiences that may be difficult to discuss utilizing traditional face-to-face modalities, particularly for marginalized populations such as female-to-male trans masculine (TM) transgender individuals. This article reviews the history, advantages, and disadvantages of online focus groups, with an emphasis for research about sensitive issues with stigmatized, rare, and/or geographically dispersed patient populations. The article then evaluates the success of online focus group discussions as a case study using data from four asynchronous online focus groups conducted between September 2015 and February 2016 that explored topics related to sexual health care access with U.S. TM adults ( N = 29). The rationale for selecting an asynchronous online methodology is described along with the unique methodological considerations that emerged in developing the study protocol. We conclude by sharing lessons learned, including innovations for maximizing participant engagement and comfort to elicit rich qualitative data.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S.

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol.

BACKGROUND: Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. GUIDELINES: Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients. METHODS: This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard. DISCUSSION: This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02401867.

Self-Reported Changes in Attractions and Social Determinants of Mental Health in Transgender Adults.

This study examined associations between changes in self-reported attractions and mental health in a community-based sample of self-identified transgender adults. Participants were purposively recruited in 2013 using bimodal sampling methods and completed a one-time survey. Multivariable logistic regression models estimated adjusted risk ratios and 95 % confidence intervals to examine associations between changes in attractions and mental health outcomes (lifetime self-harm, suicide attempts, depression diagnosis; past-week clinically significant depressive distress assessed via CES-D 10) among the entire sample (N = 452; 285 female-to-male spectrum, 167 male-to-female spectrum) and after gender transition among those who had socially transitioned (n = 205; 156 female-to-male spectrum, 49 male-to-female spectrum). Models were adjusted for known population social determinants (age, race/ethnicity, gender identity, socioeconomic status, sexual orientation identity), transgender-specific determinants (age of transgender realization, social transition, medical transition, visual gender nonconformity, non-binary gender identification), and survey mode (online vs. in-person sampling). Lifetime changes in attractions were significantly associated with increased probability of all mental health outcomes; individuals reporting any change in attractions were more likely than individuals not reporting changes to indicate lifetime self-harm, suicide attempts, depression diagnosis, and current depressive distress (all ps < .05). Changes in attractions post-social transition were not significantly associated with mental health outcomes. Many, but not all, population and transgender-specific social determinants were significantly associated with mental health in the full sample and among those who had socially transitioned. Clinical implications of findings about changes in attractions and mental health are discussed for transgender individuals.

'The big ole gay express': sexual minority stigma, mobility and health in the small city.

Recent research has examined how gay and bisexual men experience and navigate the variations in sexual minority stigma that exist across geographic contexts, with implications for their health. We extend this literature on stigma, mobility, and health by considering the unique and understudied setting of the small city. Drawing on semi-structured interviews (n = 29) conducted in two small US cities (New Haven and Hartford), we find that these small cities serve as both destinations and points of departure for gay and bisexual men in the context of stigma. New Haven and Hartford attracted gay and bisexual men from surrounding suburbs where sexual minority stigma was more prevalent and where there were fewer spaces and opportunities for gay life. Conversely, participants noted that these small cities did not contain the same identity affirming communities as urban gay enclaves, thus motivating movement from small cities to larger ones. Our data suggest these forms of mobility may mitigate stigma, but may also produce sexual health risks, thus drawing attention to small cities as uniquely important sites for HIV prevention. Furthermore, our analysis contributes to an understanding of how place, stigma and mobility can intersect to generate spatially distinct experiences of stigmatised identities and related health consequences.

Victimization and depressive symptomology in transgender adults: The mediating role of avoidant coping.

Victimization and depressive distress symptoms represent serious and interconnected public health problems facing transgender communities. Avoidant coping is hypothesized to temporarily alleviate the stress of victimization, but has potential long-term mental and behavioral health costs, such as increasing the probability of depressive symptoms. A community sample of 412 transgender adults (M age = 32.7, SD = 12.8) completed a one-time survey capturing multiple forms of victimization (i.e., everyday discrimination, bullying, physical assault by family, verbal harassment by family, childhood sexual abuse, intimate partner violence), avoidant coping, and past-week depressive symptomology. Structural equation modeling examined the mediating role of avoidant coping in the association between victimization and depressive symptomology. A latent victimization variable comprised of 6 measures of victimization was positively associated with avoidant coping, which in turn was positively associated with depressive symptoms. Victimization was also positively associated with depressive symptomology both directly and indirectly through avoidant coping. Avoidant coping represents a potentially useful intervention target for clinicians aiming to reduce the mental health sequelae of victimization in this highly stigmatized and vulnerable population. (PsycINFO Database Record

Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults.

Discrimination has been shown to disproportionately burden transgender people; however, there has been a lack of clinical attention to the mental health sequelae of discrimination, including posttraumatic stress disorder (PTSD) symptoms. Additionally, few studies contextualize discrimination alongside other traumatic stressors in predicting PTSD symptomatology. The current study sought to fill these gaps. A community-based sample of 412 transgender adults (mean age 33, SD = 13; 63% female-to-male spectrum; 19% people of color; 88% sampled online) completed a cross-sectional self-report survey of everyday discrimination experiences and PTSD symptoms. Multivariable linear regression models examined the association between self-reported everyday discrimination experiences, number of attributed domains of discrimination, and PTSD symptoms, adjusting for prior trauma, sociodemographics, and psychosocial comorbidity. The mean number of discrimination attributions endorsed was 4.8 (SD = 2.4) and the 5 most frequently reported reasons for discrimination were: gender identity and/or expression (83%), masculine and feminine appearance (79%), sexual orientation (68%), sex (57%), and age (44%). Higher everyday discrimination scores (ß = 0.25; 95% CL [0.21, 0.30]) and greater number of attributed reasons for discrimination experiences (ß = 0.05; 95% CL [0.01, 0.10]) were independently associated with PTSD symptoms, even after adjusting for prior trauma experiences. Everyday discrimination experiences from multiple sources necessitate clinical consideration in treatment for PTSD symptoms in transgender people. (PsycINFO Database Record

Characteristics of Transgender Residents of Massachusetts Cities With High HIV Prevalence.

Geographic context can influence individual risk in populations disproportionately susceptible to HIV infection, such as transgender people. We examined factors associated with residing in Massachusetts cities with the highest HIV prevalence (geographic "hotspots") in a 2013 sample of 433 transgender adults who were not infected with HIV. Residing in hotspots was associated with older age, non-White race/ethnicity, low income, incarceration history, polydrug use, smoking, binge drinking, and condomless receptive anal sex during one's most recent sexual encounter with a partner who was assigned male sex at birth. Future research to understand the interpersonal and socio-structural factors that drive localized epidemics among transgender people is warranted.

Individual- and Partnership-Level Correlates of Protective Barrier Use in a Sample of Transmasculine Adults with Diverse Sexual Partnerships.

The sexual partnerships of transmasculine adults-who were assigned female at birth and identify on the masculine gender continuum-remain understudied. This includes characteristics of transmasculine adults' sexual partnerships associated with engaging in HIV/sexually transmitted infection (STI) sexual risk behavior. This study examined individual- and partnership-level factors of transmasculine adults' sexual partnerships associated with using a protective barrier during sexual activity. Data came from cross-sectional surveys administered to 141 transmasculine adults. Participants provided demographic and sexual health information for up to three sexual partners from the past 12 months (n = 259 partnerships). Generalized estimating equations (GEEs) were used to investigate individual- and partnership-level factors associated with any use of a protective barrier during five sexual behaviors. Transmasculine participants engaged in an array of sexual behaviors with diverse sexual partners. Individual- and partnership-level factors of transmasculine adults' sexual partnerships were associated with their protective barrier use; however, these associations varied in statistical significance across the five sexual behaviors. At the individual level, younger participants had lower odds of protective barrier use during fingering or fisting. At the partnership level, protective barrier use was associated with a sexual partnership's configuration and the gender identity of a sexual partner. Relative to participants with cisgender female partners, those with cisgender male partners generally had lower odds of using a protective barrier. Study findings highlight the importance of studying factors associated with HIV/STI risk behavior located beyond the individual. These findings may have implications for improving measurements of HIV/STI-related risk for transmasculine adults.

Social Context of Depressive Distress in Aging Transgender Adults.

This study investigates the relationship between discrimination and mental health in aging transgender adults. Survey responses from 61 transgender adults above 50 ( Mage = 57.7, SD = 5.8; 77.1% male-to-female; 78.7% White non-Hispanic) were analyzed. Multivariable logistic regression models examined the relationship between gender- and age-related discrimination, number of everyday discrimination experiences, and past-week depressive distress, adjusting for social support, sociodemographics, and other forms of discrimination. The most commonly attributed reasons for experiencing discrimination were related to gender (80.3%) and age (34.4%). More than half of participants (55.5%) met criteria for past-week depressive distress. In an adjusted multivariable model, gender-related discrimination and a greater number of everyday discrimination experiences were associated with increased odds of past-week depressive distress. Additional research is needed to understand the effects of aging and gender identity on depressive symptoms and develop interventions to safeguard the mental health of this vulnerable aging population.

Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample.

Purpose: To investigate whether the prevalence of eating disorders (EDs) differs across diverse gender identity groups in a transgender sample. Methods: Secondary analysis of data from Project VOICE, a cross-sectional study of stress and health among 452 transgender adults (ages 18-75 years) residing in Massachusetts. Age-adjusted logistic regression models were fit to compare the prevalence of self-reported lifetime EDs in female-to-male (FTM), male-to-female (MTF), and gender-nonconforming participants assigned male at birth (MBGNC) to gender-nonconforming participants assigned female at birth (FBGNC; referent). Results: The age-adjusted odds of self-reported ED in MTF participants were 0.14 times the odds of self-reported ED in FBGNC participants (p=0.022). In FTM participants, the age-adjusted odds of self-reported ED were 0.46 times the odds of self-reported ED in FBGNC participants, a marginally significant finding (p=0.068). No statistically significant differences in ED prevalence were found for MBGNC individuals. Conclusions: Gender nonconforming individuals assigned a female sex at birth appear to have heightened lifetime risk of EDs relative to MTF participants. Further research into specific biologic and psychosocial ED risk factors and gender-responsive intervention strategies are urgently needed. Training clinical providers and ensuring competency of treatment services beyond the gender binary will be vital to addressing this disparity.

Creating, reinforcing, and resisting the gender binary: a qualitative study of transgender women's healthcare experiences in sex-segregated jails and prisons.

Purpose Incarcerated transgender women often require healthcare to meet their physical-, mental-, and gender transition-related health needs; however, their healthcare experiences in prisons and jails and interactions with correctional healthcare providers are understudied. The paper aims to discuss these issues. Design/methodology/approach In 2015, 20 transgender women who had been incarcerated in the USA within the past five years participated in semi-structured interviews about their healthcare experiences while incarcerated. Findings Participants described an institutional culture in which their feminine identity was not recognized and the ways in which institutional policies acted as a form of structural stigma that created and reinforced the gender binary and restricted access to healthcare. While some participants attributed healthcare barriers to providers' transgender bias, others attributed barriers to providers' limited knowledge or inexperience caring for transgender patients. Whether due to institutional (e.g. sex-segregated prisons, biased culture) or interpersonal factors (e.g. biased or inexperienced providers), insufficient access to physical-, mental-, and gender transition-related healthcare negatively impacted participants' health while incarcerated. Research limitations/implications Findings highlight the need for interventions that target multi-level barriers to care in order to improve incarcerated transgender women's access to quality, gender-affirmative healthcare. Originality/value This study provides first-hand accounts of how multi-level forces serve to reinforce the gender binary and negatively impact the health of incarcerated transgender women. Findings also describe incarcerated transgender women's acts of resistance against institutional and interpersonal efforts to maintain the gender binary and present participant-derived recommendations to improve access to gender affirmative healthcare for incarcerated transgender women.

Factors Associated with Medical Doctors' Intentions to Discriminate Against Transgender Patients in Kuala Lumpur, Malaysia.

PURPOSE: Transgender people are frequent targets of discrimination. Discrimination against transgender people in the context of healthcare can lead to poor health outcomes and facilitate the growth of health disparities. This study explores factors associated with medical doctors' intentions to discriminate against transgender people in Malaysia. METHODS: A total of 436 physicians at two major university medical centers in Kuala Lumpur, Malaysia, completed an online survey. Sociodemographic characteristics, stigma-related constructs, and intentions to discriminate against transgender people were measured. Bivariate and multivariate linear regression were used to evaluate independent covariates of discrimination intent. RESULTS: Medical doctors who felt more fearful of transgender people and more personal shame associated with transgender people expressed greater intention to discriminate against transgender people, whereas doctors who endorsed the belief that transgender people deserve good care reported lower discrimination intent. Stigma-related constructs accounted for 42% of the variance and 8% was accounted for by sociodemographic characteristics. CONCLUSIONS: Constructs associated with transgender stigma play an important role in medical doctors' intentions to discriminate against transgender patients. Development of interventions to improve medical doctors' knowledge about and attitudes toward transgender people are necessary to reduce discriminatory intent in healthcare settings.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients.

BACKGROUND: High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals. OBJECTIVE: To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21-64 years. METHODS: Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard. RESULTS: Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab. CONCLUSION: Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.

Victimization and Human Immunodeficiency Virus-Related Risk Among Transgender Women in India: A Latent Profile Analysis.

Globally, transgender women (TGW) experience multiple forms of victimization such as violence and discrimination that can place them at risk for poor sexual health. To date, research overlooks the heterogeneity in experiences of victimization among TGW. Furthermore, few studies have examined the association between victimization and sexual risk among TGW in India, despite the high burden of HIV and victimization in this community. Latent profile analysis was performed to identify patterns of victimization in a convenience sample of 299 TGW recruited from nongovernmental organizations across four states in India. Analysis of covariance was performed to examine differences in sexual risk (i.e., alcohol use before sex; inconsistent condom use with a male regular partner, a male causal partner, and a male paying partner; and having multiple sexual partners) between latent profiles. Five distinct profiles of Indian TGW were identified based on the type and severity of victimization: (1) Low victimization, (2) High verbal police victimization, (3) High verbal and physical police victimization, (4) Moderate victimization, and (5) High victimization. While controlling for age, education, income, HIV status, and marital status, results revealed that TGW in the moderate victimization and high victimization profiles had higher sexual risk than TGW in the low victimization and high verbal police victimization profiles. In addition, TGW in high verbal and physical police victimization profile had higher sexual risk than TGW in low victimization profile. These findings underscore the importance of tailoring sexual risk reduction interventions to the specific needs of TGW based on patterns of victimization.

"What's the right thing to do?" Correctional healthcare providers' knowledge, attitudes and experiences caring for transgender inmates.

RATIONAL: Incarcerated transgender individuals may need to access physical and mental health services to meet their general and gender-affirming (e.g., hormones, surgery) medical needs while incarcerated. OBJECTIVE: This study sought to examine correctional healthcare providers' knowledge of, attitudes toward, and experiences providing care to transgender inmates. METHOD: In 2016, 20 correctional healthcare providers (e.g., physicians, social workers, psychologists, mental health counselors) from New England participated in in-depth, semi-structured interviews examining their experiences caring for transgender inmates. The interview guide drew on healthcare-related interviews with recently incarcerated transgender women and key informant interviews with correctional healthcare providers and administrators. Data were analyzed using a modified grounded theory framework and thematic analysis. RESULTS: Findings revealed that transgender inmates do not consistently receive adequate or gender-affirming care while incarcerated. Factors at the structural level (i.e., lack of training, restrictive healthcare policies, limited budget, and an unsupportive prison culture); interpersonal level (i.e., custody staff bias); and individual level (i.e., lack of transgender cultural and clinical competence) impede correctional healthcare providers' ability to provide gender-affirming care to transgender patients. These factors result in negative health consequences for incarcerated transgender patients. CONCLUSIONS: Results call for transgender-specific healthcare policy changes and the implementation of transgender competency trainings for both correctional healthcare providers and custody staff (e.g., officers, lieutenants, wardens).