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To inform culturally relevant HIV prevention interventions, we explore the complexity of sex work among Peruvian transgender women. In 2015, we conducted twenty in-depth interviews and demographic surveys with transgender women in Lima, Peru to examine how transgender women enact individual- and community-level resistance strategies within a context of pervasive marginalization. Although 40% self-identified as "sex workers," 70% recently exchanged sex for money. Participants described nuanced risk-benefit analyses surrounding paid sexual encounters. Classification of clients as "risky" or "rewarding" incorporated issues of health, violence, and pleasure. Interviews highlighted context-informed decision-making (rejecting disrespectful clients, asserting condom use with specific partner types) demonstrating that motivations were not limited to HIV prevention or economic renumeration, but considered safety, health, attraction, gender validation, hygiene, and convenience. These findings underscore the complex risk assessments employed by Peruvian trans women. These individual-level decision-making and context-specific health promotion strategies represent critical frameworks for HIV prevention efforts.

IntroductionAlthough pre-exposure prophylaxis (PrEP) is a remarkable biomedical advance to prevent HIV, ongoing research on PrEP contributes to and interacts with a legacy of HIV experimentation on marginalized communities in resource-limited settings. This paper explores the complexity of PrEP research mistrust among Peruvian transgender (trans) women who completed a PrEP adherence intervention and those who refused participation (i.e. declined to enrol, voluntarily withdrew, and/or were lost to follow-up).MethodsData were derived from 86 trans women (mean age 29 years) participants in the formative (four focus groups (n = 32), 20 interviews) and the evaluation stages (34 interviews) of a social network-based PrEP intervention for trans women in Lima, Peru. The formative stage took place from May to July 2015, while the evaluative stage took place from April to May 2018. Audio files were transcribed verbatim and analysed via an immersion crystallization approach using Dedoose (v.6.1.18).ResultsThree paradoxes of trans women's participation in PrEP science as a "key" population emerged as amplifying mistrust: (1) increases in PrEP research targeting trans women but limited perceived improvements in HIV outcomes; (2) routine dismissal by research physicians and staff of PrEP-related side effects and the social realities of taking PrEP, resulting in questions about who PrEP research is really for and (3) persistent limitations on PrEP access for trans women despite increasing involvement in clinical trials, fostering feelings of being a "guinea pig" to advance PrEP science.ConclusionsFindings highlight the wisdom inherent in PrEP mistrust as a reflection of trans women's experiences that underscore the broken bonds of trust between communities, researchers and the research enterprise. PrEP mistrust is amplified through perceived paradoxes that suggest to trans women that they are key experimental participants but not target PrEP users outside of research settings. Findings highlight the urgent need to reframe mistrust not as a characteristic of trans women to be addressed through education and outreach, but as a systemic institutional- and industry-level problem replicated, manifested and ultimately to be corrected, through global HIV science.

BackgroundSubstantial research gaps exist regarding the relationship between transgender-related discrimination and substance use outcomes for transgender adults, with few studies accounting for other experiences of victimization.MethodsTransgender adults (N = 600) from Massachusetts and Rhode Island completed a survey online or in-person. Multivariable linear and logistic regression models examined the association between lifetime experiences of transgender-related discrimination using the validated 11-item Everyday Discrimination Scale (theoretical range = 0-44) and substance use outcomes: past 12-month substance use frequency, lifetime substance use disorder (SUD) diagnosis, and substance use treatment (SUTx) history. All models were adjusted for age, gender identity, race, survey modality, childhood physical/sexual abuse, intimate partner violence, and discrimination attributable to other reasons than being transgender.ResultsThe mean transgender-related discrimination score was 20.8 (SD = 9.6, range = 0-44). Overall, 11.8 % of the sample had a SUD diagnosis and 11.0 % had received SUTx. In separate multivariable models adjusted for sociodemographic and victimization experiences, the highest quartile of transgender-related discrimination was significantly associated with higher past 12-month substance use (B = 1.44; aR2 = 0.13; p = .009), SUD diagnosis (aOR = 3.64; 95 % CI = 1.46-9.07; p = .006), and lifetime treatment history (aOR = 3.93; 95 % CI = 1.50-10.21; p = .005).ConclusionsThere was a significant positive association between experiencing high levels of transgender-related discrimination and substance use outcomes among the transgender adults sampled. Longitudinal research is needed to understand the specific mediators driving these relationships and to address the implications of transgender-related discrimination on SUD treatment utilization.

BackgroundLimited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults.MethodsIn 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs.ResultsOverall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values

Purpose: The purpose of this study was to examine the extent to which transgender people have observed negative transgender-related messages in the media and the relationship between negative media message exposure and the mental health of transgender people. Methods: In 2019, 545 transgender adults completed an online survey assessing demographics, negative transgender-related media messages, violence, and mental health. Separate multivariable logistic regression models examined the association of frequency of negative media exposure and clinically significant symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and global psychological distress. Results: Mean age of the sample was 31.2 years (standard deviation [SD] = 11.2). Nearly half identified as nonbinary (42.2%), 82.0% were White, non-Hispanic, 56.9% had a college degree, and 67.0% were financially insecure. The majority reported experiencing childhood abuse (60.6%) and abuse in adulthood (58.0%). The mean frequency of exposure to negative transgender-related media was 6.41 (SD = 2.9) with 97.6% of the sample reporting exposure to negative media depictions of transgender people across a range of mediums. In separate multivariable models adjusted for age, gender identity, race, education, income, and childhood/adult abuse, more frequent exposure to negative depictions of transgender people in the media was significantly associated with clinically significant symptoms of depression (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] = 1.08-1.29; p = 0.0003); anxiety (aOR = 1.26; 95% CI = 1.14-1.40; p

BACKGROUND:HIV testing and pre-exposure prophylaxis (PrEP) are effective HIV prevention strategies often underutilized by transgender people. METHODS:Recruitment occurred in two phases to identify transgender respondents in a probability sample of adults in the United States. Transgender respondents completed a self-administered paper or web-based survey designed to assess transgender population health. Sexually active respondents (HIV-negative and had sex in the 5 years prior, N = 190) and a subsample of those at risk for sexual HIV acquisition (sex with cisgender men or transgender women, n = 120) were included in analyses. RESULTS:Of the full sample of sexually active respondents, those who were transfeminine were less likely to be familiar with PrEP; most (72%) reported favorable attitudes towards PrEP. Of those at risk for HIV acquisition, 28% had never tested for HIV. Respondents of color were more likely than white respondents to meet CDC recommendations for HIV testing. Respondents who met CDC recommendations for HIV testing were more likely to report looking online for LGBT or transgender health information. Few respondents reported currently taking PrEP (3%); those who reported higher levels of non-affirmation of their gender identity were less likely to currently use PrEP. DISCUSSION:These findings may indicate some success of HIV testing outreach programs that prioritize people at higher risk for acquiring HIV, focusing on those who are vulnerable to structural marginalization. Ongoing public health efforts are needed to increase HIV testing and PrEP awareness among transgender adults, who are disproportionately impacted by HIV.

Cisgender men partnered with transgender women are an understudied and hard to engage population in HIV prevention efforts. Relationship stigma-the anticipation of negative treatment based on having a relationship with a member of a stigmatized group-has been linked to adverse health behaviors, but it remains unclear whether different sources of relationship stigma (i.e., family, friends, and the general public) are associated with HIV risk behaviors and whether these associations may vary by men's sexual identities (e.g., gay, bisexual, and heterosexual). The current study examined associations between relationship stigma and HIV risk behaviors and whether these associations were moderated by sexual identity. We recruited a convenience sample of 185 cisgender men in primary partnerships with transgender women to participate in a one-time survey. Gay identified men reported greater levels of relationship stigma from the general public compared with heterosexually identified men. In multivariable models, higher levels of relationship stigma from the public were associated with increased odds of engaging in drug use prior to having condomless sex and receiving an STI diagnosis in the last 30 days. There were significant interaction effects such that higher levels of relationship stigma from the public were associated with both indicators of HIV risk for gay identified men but not for heterosexually identified men. Findings support the importance of HIV prevention approaches accounting for relationship stigma from the general public and the diverse sexual identities of men partnered with transgender women when seeking to increase linkage to and engagement in HIV prevention services, including biomedical prevention strategies.

Female-to-male trans masculine adults who have sex with cisgender (non-transgender) males (TMSM) represent an understudied population in relation to HIV/sexually transmitted infection (STI) risk. This study examined the role of syndemic conditions and social gender affirmation processes (living full-time in one's identified gender) in potentiating sexual risk among TMSM adults in Massachusetts, US. Cross-sectional data were restricted to TMSM who reported lifetime sexual behaviour with a cisgender male (n = 173; mean age = 29.4, SD = 9.6; 18.5% people of colour; 93.1% non-heterosexual identity; 56.1% hormones/surgery). Sexual risk outcomes were: lifetime STI diagnoses, three or more sexual partners in the previous six months, and condomless anal/vaginal sex at last encounter with a cisgender male. Age- and survey mode-adjusted logistic regression models regressed sexual risk outcomes on the main effect of syndemics (six indicators summed: binge drinking, substance use, depression, anxiety, childhood abuse, intimate partner violence), followed by the interaction of syndemics and social gender affirmation. Syndemics were associated with increased odds of all sexual risk indicators (adjusted odds ratios [aORs] = 1.32-1.55; p

Transgender young adults (TYA) are burdened by adverse mental health outcomes. Guided by intersectionality and minority stress frameworks, we compared prevalence of psychological distress and suicidality among TYA of different social identities to inform future interventions. In this secondary data analysis of 12,738 TYA, ages 18–25 years, from the 2015 United States Transgender Survey, we developed multivariable regression models examining associations between social identities and psychological distress and suicidality, adjusting for relevant covariates. Self-reported identities were used as proxies for minority stress resulting from structural oppressions related to gender binarism, transmisogyny, heterosexism, and racism. Overall, 53% met criteria for serious psychological distress, and 66% reported suicidal ideation. Statistically higher odds of serious psychological distress and suicidal ideation and plan were found for TYA assigned male compared to assigned female at birth (adjusted odds ratios [aORs] = 1.14–1.50). Nonbinary TYA assigned male at birth also had lower odds of all outcomes compared to all other TYA (aORs = 0.6–0.7). Compared to White TYA, Latiné/x TYA were more likely to experience serious psychological distress (aOR = 1.19, 95% confidence interval: 1.02, 1.39) and multiracial TYA were more likely to report suicide plan(s) and attempt(s) (aORs = 1.25–1.30). Finally, compared to heterosexual TYA, bisexual/pansexual TYA were more likely to report suicide plan(s) (aOR = 1.28, 95% confidence intervals: 1.04, 1.52), and all sexual minority TYA were more likely to report serious psychological distress and suicidal ideation (aORs = 1.31–2.00). Results highlight complex associations between intersectional minority stress and mental health outcomes among TYA. Associations between identities and mental health morbidity highlight an urgent need for targeted mental health interventions. [ABSTRACT FROM AUTHOR]

Limited national data document the prevalence of incarceration among transgender women, experiences of victimization while incarcerated, and associations of transgender status with health. Data were from the National Transgender Discrimination Survey (NTDS), a large convenience sample of transgender adults in the U.S., collected between September 2008 and March 2009. Respondents who indicated a transfeminine gender identity were included in the current study (n = 3,878). Multivariable logistic regression was used to model ever being incarcerated and experiencing victimization while incarcerated as a function of race/ethnicity and health-related indicators. Overall, 19.3% reported having ever been incarcerated. Black and Native American/Alaskan Native transgender women were more likely to report a history of incarceration than White (non-Hispanic) respondents, and those with a history of incarceration were more likely to report negative health-related indicators, including self-reporting as HIV-positive. Among previously incarcerated respondents, 47.0% reported victimization while incarcerated. Black, Latina, and mixed race transgender women were more likely to report experiences of victimization while incarcerated. Transgender women reported disproportionately high rates of incarceration and victimization while incarcerated, as well as associated negative health-related indicators. Interventions and policy changes are needed to support transgender women while incarcerated and upon release.

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. [ABSTRACT FROM AUTHOR]

Objective To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data. Methods Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity. Results Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4–88.2), specificity of 98.7% (95% CI 98.6–98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9–89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4–98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925–0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94–0.96). Conclusions In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well. [ABSTRACT FROM AUTHOR]

Background: Transgender and other gender diverse (TGD) youth of color experience stigma within healthcare. Gender affirmation can be a resilience resource; however, little is known about gender affirmation within healthcare.Purpose: This study explores TGD youth of color's experiences of stigma and gender affirmation across the entire healthcare experience and their role on motivation to seek care.Methods: In 2015, cross-sectional surveys and individual in-depth interviews were conducted among 187 TGD youth ages 16-24 living in 14 U.S. cities. Analyses followed a mixed-methods design whereby 33 participants were purposively selected for a qualitative phenomenological analysis based on quantitatively reported gender affirmation needs. Subsequent quantitative analyses examined how healthcare use differed by access to gender affirmation.Results: Participants qualitatively described experiencing stigma across multiple healthcare settings (e.g., primary care, emergency care, medical gender affirmation), including before (finding providers, scheduling), during (waiting rooms, provider interactions), and after (pharmacy) healthcare visits. Participants who quantitatively reported access to gender-affirming healthcare still described negative healthcare experiences, either because they accessed multiple healthcare services or because of prior negative experiences. Stigma and gender affirmation (both inside and outside of healthcare) influenced motivation to seek care, with variation depending on the type of care. Quantitative analyses confirmed these findings; access to gender affirmation differed for participants who delayed primary care vs. those who did not, but did not vary based on participants' use of medical gender affirmation.Conclusions: Findings highlight the importance of promoting gender-affirming healthcare environments to increase access to care for TGD youth of color. [ABSTRACT FROM AUTHOR]

Background: The purpose of this formative study was to assess barriers and facilitators to participation of transgender and gender diverse (TGD) patients in clinical research to solicit specific feedback on perceived acceptability and feasibility of research methods to inform creation of a multisite longitudinal cohort of primary care patients engaged in care at two community health centers.Method: Between September-November 2018, four focus groups (FGs) were convened at two community health centers in Boston, MA and New York, NY (N = 28 participants across all 4 groups; 11 in Boston and 17 in New York). FG guides asked about patient outreach, acceptability of study methods and measures, and ideas for study retention. FGs were facilitated by TGD study staff, lasted approximately 90 min in duration, were audio recorded, and then transcribed verbatim by a professional transcription service. Thematic analyses were conducted by two independent analysts applying a constant comparison method. Consistency and consensus were achieved across code creation and application aided by Dedoose software.Results: Participants were a mean age of 33.9 years (SD 12.3; Range 18-66). Participants varied in gender identity with 4 (14.3%) men, 3 (10.7%) women, 8 (28.6%) transgender men, 10 (35.7%) transgender women, and 3 (10.7%) nonbinary. Eight (26.6%) were Latinx, 5 (17.9%) Black, 3 (10.7%) Asian, 3 (10.7%) another race, and 5 (17.9%) multiracial. Motivators and facilitators to participation were: research creating community, research led by TGD staff, compensation, research integrated into healthcare, research applicable to TGD and non-TGD people, and research helping TGD communities. Barriers were: being research/healthcare averse, not identifying as TGD, overlooking questioning individuals, research coming from a 'cisgender lens", distrust of how the research will be used, research not being accessible to TGD people, and research being exploitative.Conclusion: Though similarities emerged between the perspectives of TGD people and research citing perspectives of other underserved populations, there are barriers and facilitators to research which are unique to TGD populations. It is important for TGD people to be involved as collaborators in all aspects of research that concerns them. [ABSTRACT FROM AUTHOR]

In the United States, transgender women are disproportionately burdened by HIV infection. Research aimed at curbing the HIV epidemic for this population may benefit from innovative technology to engage participants in research. Adult transgender women (n = 41) from six cities in the southern and eastern United States participated in seven online focus groups between August 2017 and January 2018. Analyses focused on perceived acceptability of novel technologies for research purposes, particularly HIV self-testing (HIVST) and remote data collection through a mobile app. While participants noted a number of benefits to HIVST and remote study participation, including increased participant engagement and sentiments of agency, they also expressed concerns that may impact HIVST and remote participation including housing instability, inconsistent access to technology, and confidentiality. Study findings provide insight into gaps that must be addressed when using technology-enhanced methods to support HIV testing and research participation among transgender women in the US. Substantial effort is required on the part of investigators to ensure equitable access across subgroups and, thus, minimize bias to avoid reproducing health disparities in research. [ABSTRACT FROM AUTHOR]

Transmasculine people are at risk of cervical cancer but have lower rates of cervical cancer screening than cisgender women. Disaffirmation of the patient's gender and unequal power dynamics between patient and provider during screening contribute to patient unwillingness to be screened. The mechanisms by which the balance of power may be shifted between patient and provider, and by which gender is constructed during the Pap test, are not well understood. A qualitative study using a modified grounded theory approach was undertaken to analyse patient interview and provider interview and focus group data pertaining to power and gender in the context of cervical cancer screening among transmasculine individuals. The study was conducted at an LGBTQ-focussed health centre in Boston, USA. Processes by which power is enacted included constraining or affirming patient choice, mitigating or exacerbating vulnerability, and self-advocacy. Gendering processes included naming patients and their bodies, invoking gender norms, de-gendering/re-gendering Pap tests, and othering or normalising trans bodies. The interplay between these processes promotes or constrains patient agency over body and health, impacting patient care, patient-provider interaction, and service utilisation. Understanding patient and provider roles in power and gender dynamics are critical for the provision of patient-centred care. [ABSTRACT FROM AUTHOR]

Objectives: Transgender men who have sex with men (TMSM) represent an understudied population in relation to screening for HIV and sexually transmitted infections (STIs). We examined HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse US nationwide sample of TMSM.Methods: Data from a cross-sectional online convenience sample of 192 TMSM were analysed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioural factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.Results: More than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past 6 months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing. Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs. Furthermore, TMSM residing in the South were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year. Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past 6 months.Conclusions: These findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behaviour. Efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex, are needed. [ABSTRACT FROM AUTHOR]

As awareness of issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. Often these narratives are based on binary constructions about both sexual orientation and gender identity. The lack of diverse, representative cultural narratives has implications for identity development and sexual health. Transgender men who have sex with cisgender men in particular represent an understudied and overlooked population who likely experience unique developmental tasks related to the intersection of socially stigmatised sexual orientation and gender identities. This study explores sexual orientation and gender identity development among a sample of young adult transgender men who have sex with men. In-depth interviews using a modified life history method were conducted with 18 young men. Interview transcripts were coded using open, narrative and focused coding methods. Participants discussed milestones in the development of their sexuality and gender identity that map onto existing models, but also described ways in which these processes overlap and intersect in distinct ways. Findings highlight the need for human development models of sexual orientation and gender identity that integrate multiple identity processes. Implications for future research and practice to increase support for young adult transgender men are discussed. [ABSTRACT FROM AUTHOR]

Healthcare access is important for achieving health equity across vulnerable social groups. However, stigma can be a barrier for accessing healthcare among black transgender and gender diverse youth (TGDY) in the U.S. Using a resilience approach, this article examines the role of gender affirmation within healthcare to determine if it can mitigate the negative relationship between stigma and healthcare use. Data include responses from 110 black TGDY from 14 U.S. cities. Multiple logistic regression models were fit to determine relationships between stigma in healthcare (anticipated and enacted), gender affirmation in healthcare, and delayed/nonuse of primary care. Interaction terms were included to determine if gender affirmation moderates the relationship between stigma and healthcare nonuse. In the main effects model, gender affirmation was the only variable statistically associated with healthcare nonuse. The interaction between gender affirmation and enacted stigma was not significant, but gender affirmation moderated the relationship between anticipated stigma and healthcare nonuse. For individuals who did not have their gender affirmation needs met, as anticipated stigma increased, healthcare nonuse also increased; however, this did not occur for those who had their gender affirmation needs met. Findings suggest that gender affirmation within healthcare is important for increasing access to care among black TGDY. Interventions should consider how to increase gender affirmation among healthcare providers and within healthcare settings. Additional research using an intersectional approach to understand the experiences of black TGDY is needed to highlight the unique healthcare needs of this population. [ABSTRACT FROM AUTHOR]

• Transgender and gender diverse (TGD) people experience mental health inequities. • Gender euphoria (GE)—positive emotions in gender—may encourage positive mental health. • GE differed by race, gender, insurance, and hormone use. • GE associated with reduced gender dysphoria and alcohol misuse, and increased resilience. • GE may be a promising mental health target for TGD peoplee. Transgender and gender diverse (TGD) people are affected by mental health inequities. Gender euphoria—positive emotions or joy in gender—may be associated with positive mental health. Between February 2019–July 2021, we surveyed 2,165 adult TGD patients (median age = 28 years; 29.2 % people of color; 29.6 % nonbinary; 81.0 % taking hormones) evaluating gender euphoria and mental health. Overall, 35.0 % self-reported gender euphoria, 50.9 % gender dysphoria, 23.5 % alcohol misuse, and 44.5 % resilience. Gender euphoria differed by race, gender, insurance, and hormone use, and was associated with reduced gender dysphoria (adjusted Odds Ratio[aOR] = 0.58; 95 % confidence interval [95 %CI] = 0.47–0.72) and alcohol misuse (aOR = 0.75; 95 %CI = 0.60–0.95), and increased resilience (aOR = 1.31; 95 %CI = 1.07–1.61). The construct of gender euphoria may be a promising mental health target. [ABSTRACT FROM AUTHOR]

Transgender adults may avoid medical settings due to concerns about discrimination or past experiences of maltreatment. Emerging evidence shows improved outcomes and psychosocial functioning when transgender adolescents receive gender-affirming care, but little is known about transgender adolescents' experiences in primary care. The objective of this study was to learn about the experiences in primary care of transgender and gender nonconforming (TGN) adolescents and their recommendations for primary care practices and clinicians. Participants were recruited from primary care clinics, gender care clinics, and list serves. Semistructured qualitative interviews were conducted with 20 TGN adolescents aged 13–21 years (75% white/non-Hispanic, average age 16.7 years). Participants answered questions about primary care experiences, how to improve care, suggestions regarding how to ask about gender identity, and recommendations for making offices more welcoming for TGN adolescents. Interviews were transcribed verbatim, coded, and analyzed for themes. Overall, participants reported positive experiences in primary care. Most participants commented on distress resulting from being called the incorrect name or the incorrect pronoun. Several concrete recommendations emerged from the interviews, including asking all patients about their gender identity and pronouns at every primary care visit and not asking about gender identity when caregivers are in the room. Participants emphasized the importance of using their affirmed name and pronouns and wanted providers to be knowledgeable about transgender health. Delivery of primary care services for transgender adolescents may be optimized if offices provide a welcoming environment, use correct names and pronouns, and discuss gender confidentially with patients. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) takes on unique dimensions when directed against transgender individuals, with perpetrators leveraging transphobia to assert power and control. Standard IPV measurement tools do not assess this type of IPV. Four questions to assess transgender-related IPV (T-IPV) were developed: (a) being forced to conform to an undesired gender presentation or to stop pursuing gender transition; (b) being pressured to remain in a relationship by being told no one would date a transgender person; (c) being "outed" as a form of blackmail; and (d) having transition-related hormones, prosthetics, or clothing hidden or destroyed. The T-IPV tool was administered to 150 female-to-male transmasculine individuals completing a study of cervical cancer screening in Boston from March 2015-September 2016. Construct validity was assessed by examining correlations between T-IPV and two validated screeners of other forms of IPV (convergent) and employment status and fruit consumption (divergent). The association between T-IPV and negative health outcomes (posttraumatic stress disorder [PTSD], depression, psychological symptoms, binge drinking, number of sexual partners, and sexually transmitted infection [STI] diagnosis) were also calculated. Lifetime T-IPV was reported by 38.9%, and 10.1% reported past-year T-IPV. T-IPV was more prevalent among those who reported lifetime physical (51.7% vs. 31.7%, p =.01) and sexual (58.7% vs. 19.4%, p <.001) IPV than those who did not. Lifetime T-IPV was associated with PTSD (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI] = [1.04, 4.80]), depression (AOR = 2.70, 95% CI = [1.22, 5.96]), and psychological distress (AOR = 2.82, 95% CI = [1.10, 7.26]). The T-IPV assessment tool demonstrated adequate reliability and validity and measures a novel type of abuse that is prevalent and associated with significant mental health burden. Future work should further validate the measure and pilot it with male-to-female transfeminine individuals. [ABSTRACT FROM AUTHOR]

In the United States, sexually transmitted infections (STIs) confer significant morbidity in adolescents and young adults. STIs are not well characterized in transgender and other gender minority youth (TGMY) who have a gender identity that differs from the sex assigned to them at birth. This study sought to fill this gap. In 2015–2016, the Adolescent Medicine Trials Network for HIV/AIDS Interventions conducted Protocol 130, Affirming Voices for Action, enrolling a diverse sample of TGMY 16–24 years of age from 14 US geographic locations. Multivariable analyses regressed lifetime STI diagnosis on "situated vulnerabilities" (demographics, social/economic issues, mental/behavioral health conditions, and health care experience). Approximately one-third were living with HIV infection (31%); 33% had a history of one or more STIs, excluding HIV. The most frequently diagnosed STIs were 55% chlamydia, 48% syphilis, and 47% gonorrhea. The odds of STI was 4.06 times higher for trans feminine youth assigned a male sex at birth compared to trans masculine youth assigned a female sex at birth (p = 0.03). Additional risk factors for lifetime STI were as follows: nonbinary gender identity (p = 0.004), medical gender affirmation (p = 0.03), and transactional sex (p = 0.01). Nearly one-third (31%) reported condomless vaginal and/or anal sex in the last 6 months, suggesting a need for ongoing STI prevention, screening, diagnosis, and treatment. TGMY are a vulnerable group to STIs in need of public health attention. Clinical care for STIs will benefit from considering risk factors facing youth in general (e.g., sex work), alongside those vulnerabilities unique to TGMY (e.g., medical gender affirmation). [ABSTRACT FROM AUTHOR]

Background Transgender women are disproportionately incarcerated in the US relative to the general population. A dearth of research has explored the factors that predict incarceration among transgender women or the longitudinal impact of incarceration on the health of this population. Methods Between 2012 and 2015, 221 transgender women ages 16–29 from Boston, MA and Chicago, IL were prospectively assessed at baseline, 4, 8 and 12 months. Mixed effects models were used to identify risk factors for incarceration and examine whether incarceration predicts somatic, anxiety and depressive symptoms, illicit drug use, and binge drinking over time, controlling for baseline psychiatric and substance use disorders. Results Overall, 38% experienced incarceration, before (33%) and during (18%) the study period. Significant independent predictors of recent incarceration included sex work, recent homelessness, school dropout and number of times incarcerated prior to enrollment while recent incarceration significantly predicted somatic symptoms and illicit drug use over time. Conclusions Incarceration burden is high in young transgender women. Both structural and individual risk factors predict incarceration and poor health, suggesting the need for multilevel interventions to prevent incarceration and support young transgender women during incarceration and upon release. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective This study assessed the unique coping strategies of transgender and gender nonconforming (TGNC) individuals in the United States used to manage gender-related stress, and examined associations between specific coping profiles and mental health. Methods Data were from 316 participants in the 2014-2015 Transgender Stress and Health Study, an online study of TGNC mental and sexual health. A factor analysis of the coping measure (Brief COPE) was followed by a k-means cluster analysis to evaluate distinct profiles of coping with gender-related stress. Proportional odds models and logistic regression models indicated how coping profiles related to levels of self-reported depressive symptoms and suicidality. Results A 4-factor structure was identified with three distinct profiles of coping with gender-related stress, each representative of the frequency (high or low) in which participants used functional and dysfunctional coping strategies: (a) high-functional/low-dysfunctional, (b) high-functional/high-dysfunctional, and (c) low-functional/low-dysfunctional. There were significant differences in depressive symptoms and suicidality based on distinct gender-related coping profiles. The high-functional/high-dysfunctional group reported significantly poorer mental health compared with the high-functional/low-dysfunctional group. Conclusion To improve mental health outcomes in TGNC individuals, health providers and researchers should strive to not only promote functional coping strategies for managing gender-related stress but also decrease dysfunctional coping strategies. [ABSTRACT FROM AUTHOR]