Connecting the Dots: Examining Transgender Women’s Utilization of Transition-Related Medical Care and Associations with Mental Health,Substance Use,and HIV

Findings on access to general healthcare for transgender people have emerged, but little is known about access to transition-related medical care for transwomen (i.e., hormones, breast augmentation, and genital surgery). Transgender women have low access to general medical care and are disproportionately at risk for substance use, mental illness, and HIV. We conducted an analysis to determine if utilization of transition-related medical care is a protective factor for health risks to transgender women and to investigate if care differs by important demographic factors and HIV status. A secondary analysis was conducted using data from a 2010 HIV surveillance study using respondent-driven sampling to recruit 314 transwomen in San Francisco. Survey-corrected logistic regression models were used to estimate odds ratios for six psychosocial health problems—binge drinking, injection drug use, anxiety, depression, suicidal ideation, and high-risk intercourse—comparing various levels of utilization of transition-related medical care. Odds ratios were also calculated to determine if utilization of transition-related medical care was related to less overlap of risk domains. We found that Latina and African American transwomen had significantly lower estimated utilization of breast augmentation and genital surgery, as did transwomen who identified as transgender rather than female. Overall, utilization of transition-related medical care was associated with significantly lower estimated odds of suicidal ideation, binge drinking, and non-injection drug use. Findings suggest that utilization of transition-related medical care may reduce risk for mental health problems, especially suicidal ideation, and substance use among transwomen. Yet, important racial/ethnic and gender identity disparities in utilization of transition-related medical care need to be addressed.     

In Their Own Words: How Trans Women Acquired HIV Infection

AIDS and Behavior - Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM)...     

A Qualitative Examination of Respondent-Driven Sampling (RDS) Peer Referral Challenges Among Young Transwomen in the San Francisco Bay Area

Background

Efforts have focused on developing innovative recruitment strategies to engage the most marginalized of populations in public health research. Respondent-driven sampling (RDS) has been found to be an effective sampling strategy for hard-to-reach, hidden populations. Though studies have documented RDS peer referral as challenging, literature contextualizing these challenges is scant and rarely do they discuss the role of Internet technologies.

Objective

The objective of the study was to explore reasons for peer referral challenges in a human immunodeficiency virus (HIV) risk and resilience study among a hidden population of youth, specifically, young transwomen. These findings amplify the unique opportunities Internet technologies bring to public health research and methodology.

Methods

We conducted focused, semistructured, qualitative interviews with 16 young transwomen to investigate the reasons why youth did or did not refer peers to an RDS study for transwomen ages 16-24 in the San Francisco Bay Area. Qualitative interview data were coded and analyzed using grounded theory.

Results

Participants discussed specific barriers and facilitators related to four factors that include study design, study implementation, community characteristics, and individual characteristics, which contributed to RDS peer referral challenges.

Conclusions

Our grounded theory analysis identifies important considerations for future RDS studies with hidden youth populations. Exploring research participants’ experiences is integral in strengthening future epidemiologic research efforts that plan to use RDS to sample and estimate the hidden epidemics among at-risk youth and transgender women. Additionally, Internet technologies and Web-based adaptations offer solutions to traditional RDS peer referral challenges, having the potential to increase accessibility and use among hidden youth populations.     

The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

Significant health disparities exist for transgender female (trans*female) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16–24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N = 216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95 % CI 1.4–5.0), depression (AOR, 2.6; 95 % CI 1.2–5.9), and stress related to suicidal thoughts (AOR 7.7, 95 % CI 2.3–35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95 % CI 1.2–10.8), PTSD (AOR 2.1; 95 % CI 1.1–4.2) and stress related to suicidal thoughts (AOR 4.3, 95 % CI 1.5–13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of trans*female youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.     

Housing and income effects on HIV-related health outcomes in the San Francisco Bay Area – findings from the SPNS transwomen of color initiative

Transwomen of color are disproportionately impacted by HIV and may have worse health outcomes than other populations. This analysis was conducted to examine structural factors associated with poor health outcomes among transwomen of color living with HIV in the San Francisco Bay Area (N =?159). Univariate and multivariable analyses were conducted to determine if structural factors were associated with poor HIV-related health outcomes. A majority of participants were Black or African American (110/159, 69.2%), 32 (20.1%) identified their primary race/ethnicity as Hispanic or Latino/a or Spanish, and 17 (10.7%) identified as another race/ethnicity. Transwomen of color in our sample faced extreme structural barriers, including residential transience, extreme low income, high prevalence of running out of money in the last six months, high rates of food insecurity, high prevalence of income via entitlement programs, engagement in sex work and other illicit activities for income. Unstable housing was the structural factor most consistently associated with poor health outcomes along the HIV care continuum and may explain engagement in other sources of income generation. Interventions are needed that go beyond the individual and health care-level to address needs for housing and economic opportunities to improve HIV care outcomes among transwomen of color living with HIV in the San Francisco Bay Area.     

Improved PrEP Awareness and Use among Trans Women in San Francisco,California

AIDS and Behavior - Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of...     

Examining the Effects of Transphobic Discrimination and Race on HIV Risk Among Transwomen in San Francisco

Transwomen, in particular transwomen of color (TWOC), are among the most vulnerable populations at risk for HIV. This secondary analysis is organized using a gender minority stress framework to examine the effects of transphobic discrimination and race on HIV risk factors. We describe the sample of 149 HIV- adult transwomen in San Francisco and use binary logistic regression to examine the relationship between levels of transphobic discrimination and TWOC status on binge drinking and condomless receptive anal intercourse (CRAI), controlling for potential confounders. Those with high levels of transphobic discrimination had 3.59 fold greater odds of engaging in binge drinking compared to those who reported a low level of transphobic discrimination (95% CI 1.284–10.034; P = 0.015). TWOC had nearly threefold greater odds of CRAI compared to white transwomen (95% CI 1.048–8.464; P = 0.040). We discuss implications for gender minority stress research and future interventions for this population.     

A Web 2.0 and Epidemiology Mash-Up: Using Respondent-Driven Sampling in Combination with Social Network Site Recruitment to Reach Young Transwomen

Respondent-driven sampling (RDS) peer referral has been proven to be an effective recruitment method for hard-to-reach populations; however, its application in diverse populations is limited. Recruitment occurred in two phases: RDS-only followed by development and implementation of an online social network strategy in combination with RDS peer referral (RDS + SNS). Compared to RDS-only, RDS + SNS reached a sample that was younger (χ² = 9.19, P = .03), more likely to identify with a non-binary gender identity (χ² = 10.4247, P = .03), with less housing instability (50.5 vs. 68.6 %, χ² = 9.0038, P = .002) and less sex work (19.7 vs. 31.4 %, χ² = 5.0798, P = .02). Additionally, we describe lessons learned as a result of implementing our online social network strategy. Our findings underscore the importance of integrating Internet-driven strategies to meet challenges in sample diversity and recruitment of young transwomen.