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Recent policies have restricted the rights of the US transgender people; there is a need to explore transgender people’s knowledge and attitudes regarding such policies and related mental health. In 2019, 580 transgender adults living in the Northeastern US completed a survey assessing demographics, knowledge/attitudes toward transgender-related policies, and mental health. Multivariable logistic regression models, adjusted for age, gender, race, and prior abuse, were fit to examine the association of concerns about the implementation of discriminatory policies and depression, anxiety, and post-traumatic stress disorder (PTSD). Many participants were confused about the status of federal and state protections for transgender people, and 48.4% were concerned that their state would pass policies that took away transgender rights. In adjusted models, compared to participants who were not concerned, those who were concerned about the enactment of state-level, anti-transgender policies had greater odds of depression, anxiety, and PTSD (p

Objectives. To examine differences in HIV prevalence and experiences of discrimination within the trans women community in California’s San Francisco Bay Area. Methods. Intersectional positions were constructed on the basis of race/ethnicity (non-Hispanic White, non-Hispanic Black, Latina) and gender identity (female identifying, transgender identifying). We used baseline data from the Trans*National study (2016–2017) to construct regression models that estimated racial/ethnic differences in the attribution of discrimination experienced and, along with surrogate measures for intersectionality, estimated risk among those who were dually marginalized (racial/ethnic minority and transgender identifying). Margins plots were used to visually compare absolute risk across all intersectional positions. Results. Black and Latina trans women were more likely to be HIV positive than non-Hispanic White trans women. In several of the study domains, we estimated a lower risk of reporting discrimination among dually marginalized trans women than among White female-identifying trans women. Conclusions. Quantitative intersectionality methods highlight the diversity of experiences within the trans women community and reveal potential measurement challenges. Despite facing multiple forms of systemic marginalization, racial/ethnic minority trans women report less discrimination than White trans women. Subjective reporting of discrimination likely undercounts risks among racial/ethnic minorities.

The burden of morbidity among privately insured transgender people is largely unknown. We identified transgender people enrolled in private insurance (using claims from 2001–19) and compared their ...

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

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.

Gay and bisexual men might face unique, status-based competitive pressures given that their social and sexual relationships often occur with other men, who are known to compete for social and sexual gain. In a multistage study, we delineated intraminority gay community stress theory-that status-focused elements of the gay community challenge the mental health of gay and bisexual men. We first created a measure of gay community stress with items derived from qualitative interviewing (n = 49); calculated its psychometric properties, including 1-year temporal stability (n = 937); and confirmed its structural stability in distinct samples (n = 96; n = 1,413). Being stressed by perceiving the gay community's focus on sex, focus on status, focus on competition, and exclusion of diversity predicted gay and bisexual men's mental health over-and-above a comprehensive battery of traditional minority stressors (β = .17, p < .01) and mediated the association between one's gay community status and mental health. To examine the impact of individual differences in status concerns (i.e., about masculinity, attractiveness, and wealth) on gay and bisexual men's feelings of within-community exclusion, a series of experiments manipulated (a) the sexual orientation (gay vs. heterosexual) of rejecters (n = 103), (b) the social status of gay rejecters (n = 83), and (c) whether rejection from gay and bisexual rejecters was status-based or nonstatus-based (n = 252). Overall, these experiments provide partial support for the possibility that gay and bisexual men's status concerns underlie their experience of gay community stress. Together, these studies advance psychological and sociological accounts of gay and bisexual men's mental health beyond minority stress theory, with implications for intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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.

Background People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. Methods We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. Results The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p p Conclusion We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

BACKGROUND: Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. METHODS: From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences (p < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews (n = 172) contextualized survey findings. RESULTS: The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. CONCLUSIONS: Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.

Background Substantial 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. Methods Transgender 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. Results The 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). Conclusions There 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.

Background Transgender men (TM) have a male, masculine, or nonfemale gender identity, yet were assigned female sex at birth on the basis of their external genitalia. The majority of TM are at risk of infection with one of several high-risk strains of the human papillomavirus (hr-HPV), acquired primarily through sexual contact, that cause 99.7% of cervical cancers. This study aimed to explore the association between sexual behaviors and current cervical hr-HPV infection in TM with a cervix. Methods The primary aim of this analysis was to test for an association between participant self-report of sexual contact with a penis in the past 1 year and current infection with cervical hr-HPV as measured by provider-collected cervical HPV DNA assay. This is a secondary analysis of a bio-behavioral sexual health study conducted at a health center in Boston, MA from 2015 to 2016. Analysis was conducted using logistic regression with significance level set at P less than 0.05; the primary analysis was adjusted for self-reported age, current tobacco use, years of testosterone use, and HPV vaccination status. Results Overall prevalence of hr-HPV was 15.9%. In adjusted analyses, participants reporting receptive penile vaginal sex with any of their most recent 3 sexual partners in the past 12 months had more than 5 times greater odds of current hr-HPV infection than those reporting no penile sex of any kind during this timeframe (odds ratio, 5.23; 95% confidence interval, 1.61-17.02). Conclusions Vaginal-receptive penile sex in the last 12 months was associated with a 5-fold increased odds of cervical high-risk HPV infection among TM. Findings can inform future population level study of associations between sexual behaviors and hr-HPV risk, which could lead to more individualized approaches to screening.

Background In the U.S., transgender and gender diverse (TGD) populations face structural, interpersonal, and individual barriers to healthcare. Less is known, however, about the HIV prevention and treatment experiences of TGD youth in the U.S. The current study was developed to fill this research gap. Methods This article describes the research protocol for a multi-site, U.S.-based mixed-methods study that sought to identify the multi-level facilitators and barriers that influence participation of TGD youth in various stages of the HIV prevention (e.g., pre-exposure prophylaxis uptake) and care continua. A sample of diverse TGD youth ages 16–24 was recruited from 14 U.S. sites. TGD youth participants completed a one-time, in-person visit that included an informed consent process, computer-based quantitative survey, and in-depth qualitative interview assessing experiences accessing HIV prevention and/or care services. Providers serving TGD youth were recruited from the same 14 sites and completed a one-time visit via phone that included informed consent, demographic questionnaire, and in-depth qualitative interview assessing their experiences providing HIV prevention or treatment services to TGD youth. Results Overall, 186 TGD youth ages 16–24 and 59 providers serving TGD youth were recruited and enrolled from across the 14 U.S. sites. TGD youth participants had a mean age of 20.69; 77.3% youth of color; 59.7% trans-feminine; 15.5% trans-masculine; 24.9% non-binary; 53.6% family income under poverty level. Providers included medical and mental health providers as well as case manager/care coordinators, HIV test counselors, and health educators/outreach workers. Providers were 81.3% cisgender and 30.5% people of color. Successes with community-engagement strategies and gender-affirming research methods are reported. Conclusions This study addresses critical gaps in current knowledge about the HIV prevention and care experiences of TGD youth. Findings have implications for the development of HIV interventions across levels to support the health and well-being of TGD youth. Future research is warranted to replicate and expand on lessons learned regarding recruitment and engagement of communities of TGD youth, including longitudinal designs to assess engagement across their developmental stages. Lessons learned working with TGD youth through developing and implementing the study protocol are shared. Trial registration Registered on ClinicalTrials.gov on 05/20/2015 (NCT02449629).

There remains a limited understanding of current levels of transgender-related knowledge and acceptance among members of the general public. This study sought to develop and psychometrically evaluate a transgender knowledge, attitudes, and beliefs (T-KAB) scale in the general US population. We developed and evaluated the reliability and validity of the T-KAB scale in two phases. In phase one, we developed the T-KAB scale through a robust, iterative process that included a literature review; expert feedback from cisgender and transgender professionals engaged in psychometrics and transgender health; review of prior qualitative interviews with transgender individuals, healthcare providers with a range of experience caring for transgender patients, and members of the general population; and pilot testing. In phase two, a geographically diverse convenience sample of 195 adults recruited online from the US general population completed the T-KAB scale and measures to assess scale validity. Factor analyses revealed a 22-item, 3-factor measure representing: acceptance of the gender spectrum, social tolerance, and comfort and contact related to transgender people. The scale demonstrated strong internal consistency (α = .97) and evidence of convergent and discriminant validity. Additionally, members of the general population were found to have moderate levels of transgender acceptance overall and across the three subscales. The T-KAB scale is a valid and reliable psychometric tool. Future application of the scale should seek to identify socio-demographic, cultural, and geographic factors driving lower T-KAB scores in order to identify subpopulations that would benefit from interventions to improve transgender-related knowledge, attitudes, and beliefs in the general population.

Background: Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial problems may accelerate HIV acquisition and transmission via elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of seven psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active young transgender women (YTW) in the United States. Methods: Between 2012 and 2015, 233 YTW from Boston, MA and Chicago, IL completed behavioral surveys at baseline, 4-, 8-, and 12-months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and condomless anal or vaginal sex (CAVS) among YTW. Findings: The prevalence of seven psychosocial syndemic problems was substantial at baseline and remained high at each time point: 42.1% clinically significant depressive symptoms; 6.4% polydrug use past 4 months (>3 drugs used, excluding stimulants); 15.9% stimulant use past 4 months; 7.7% heavy alcohol use past 4 month (≥ 4 drinks every day or ≥ 6 drinks on a typical day when drinking); 10% childhood sexual abuse; 41.7% experiencing lifetime intimate partner violence; and 68.6% lifetime transgender specific victimization. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial syndemic problems and CAVS over time (with the greatest adjusted odds ratio among those with 5 or more psychosocial problems; aOR=3.27; 95% confidence interval: 1.14-9.41). Interpretation: The accumulation of "syndemic" psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial syndemic problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services for this population. Funding: R01MH094323 from the National Institute of Mental Health. Declaration of Interest: All authors declare that they have no conflict of interest. Ethical Approval: The study was approved by institutional review boards at Ann & Robert H. Lurie Children’s Hospital and The Fenway Institute, Fenway Health. Written informed consent was obtained for each participant with parental consent waived for minors (aged 16-17 years).

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.

Purpose: This study examined whether older age moderates the association between gender-affirming medical treatment and quality of life (QOL) among transgender individuals. Methods: Transgender men and women from the National Transgender Discrimination Survey who had either recently or never undergone medical treatment were included (n = 2420). A moderation analysis was utilized. Results: As predicted, participants who initiated medical treatment had higher QOL than those who did not. Age moderated this association. The QOL difference was greater for older than for younger transgender individuals. Conclusion: Among all transgender men and women, gender-affirming medical treatment can be especially beneficial for elders.

OBJECTIVES: Given that prior mistreatment can lead to heightened vigilance to and perceptions of future rejection, the present study examined whether this heightened vigilance, known as rejection sensitivity, mediates the association between healthcare mistreatment and healthcare avoidance in trans masculine (TM) adults. METHOD: Between 2015 and 2016, 150 TM adults completed a comprehensive survey assessing socio-demographics, sexual health, and healthcare experiences. A 5-item scale assessing participants’ sensitivity to rejection in healthcare scenarios was administered and psychometrically evaluated. Structural equation modeling was used to test whether rejection sensitivity in healthcare mediated the relationship between lifetime mistreatment in healthcare and past 12-month healthcare avoidance among TM adults. RESULTS: Overall, 68% of participants had experienced some form of mistreatment in healthcare in their lifetime and 43% had avoided healthcare in the past 12 months. For 5% of the sample, healthcare avoidance in the past 12 months resulted in a medical emergency. Path analyses revealed that healthcare mistreatment was positively correlated with rejection sensitivity and sensitivity was positively correlated with past 12-month healthcare avoidance. Rejection sensitivity mediated the relationship between mistreatment and healthcare avoidance (all p-values < 0.05). CONCLUSION: Rejection sensitivity may contribute to healthcare avoidance among stigmatized TM patients; however, longitudinal research is needed to establish the temporal ordering of these processes. Multilevel interventions to reduce healthcare discrimination and help TM adults cope with the psychological and behavioral consequences of stigma are recommended.

BACKGROUND: Limited 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. METHODS: In 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. RESULTS: Overall, 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, reported 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

Background Valid and reliable quality measures can help catalyze improvements in health care. The care of transgender patients is ripe for quality measurement, as there is increasing awareness of the increasing prevalence of this population and the urgency of improving the health care they receive. While best practices may not exist for some aspects of transgender health care, other aspects are characterized by well-developed and highly evidence-based recommendations. Our objective was to create a list of potential quality measures for transgender care. Methods and results In consultation with our advisory panel, which consisted of clinical and academic experts in transgender medicine, we selected eight prominent clinical practice guidelines of transgender health care for review. Our four team investigators carefully reviewed all eight clinical practice guidelines. Through the course of multiple consensus-building meetings, we iteratively refined items until we had agreed upon a list of forty potential quality measures, all of which met the criteria for quality measures set forth in the Center for Medicare and Medicaid Services Blueprint for developing quality measures. Conclusions This manuscript explains the origin of the quality measures we developed, and also provides a useful roadmap to any group hoping to develop quality measures for a field that has not previously had any.

Transgender people incarcerated1 around the world remain a “vulnerable group,” and continue to experience significant mistreatment, human rights violations, and erasure of their gender identity, co...

Background Large administrative databases often do not capture gender identity data, limiting researchers' ability to identify transgender people and complicating the study of this population. Objective The objective of this study was to develop methods for identifying transgender people in a large, national dataset for insured adults. Research design This was a retrospective analysis of administrative claims data. After using gender identity disorder (GID) diagnoses codes, the current method for identifying transgender people in administrative data, we used the following 2 strategies to improve the accuracy of identifying transgender people that involved: (1) Endocrine Disorder Not Otherwise Specified (Endo NOS) codes and a transgender-related procedure code; or (2) Receipt of sex hormones not associated with the sex recorded in the patient's chart (sex-discordant hormone therapy) and an Endo NOS code or transgender-related procedure code. Subjects Seventy-four million adults 18 years and above enrolled at some point in commercial or Medicare Advantage plans from 2006 through 2017. Results We identified 27,227 unique transgender people overall; 18,785 (69%) were identified using GID codes alone. Using Endo NOS with a transgender-related procedure code, and sex-discordant hormone therapy with either Endo NOS or transgender-related procedure code, we added 4391 (16%) and 4051 (15%) transgender people, respectively. Of the 27,227 transgender people in our cohort, 8694 (32%) were transmasculine, 3959 (15%) were transfeminine, and 14,574 (54%) could not be classified. Conclusion In the absence of gender identity data, additional data elements beyond GID codes improves the identification of transgender people in large, administrative claims databases.

BACKGROUND Male sex workers (MSW) are disproportionately affected by HIV/AIDS, with an estimated HIV prevalence in the United States of 19.3%. Existing research suggests that MSW are also at risk of adverse psychosocial problems. Cross-sectional studies of MSW have suggested that co-occurring epidemics or a "syndemic" of psychosocial problems may increase vulnerability to HIV acquisition/transmission by elevated sexual risk. To the best of our knowledge, there are no published studies examining this relationship longitudinally among MSW. This study examined how a syndemic of 6 psychosocial problems result in additive risk for condomless anal sex (CAS) with male clients among a multicity, longitudinal cohort of MSW. SETTING Community-based organization and health center in 2 Northeastern US cities. METHODS Between 2015 and 2017, 100 MSW from Boston, MA and Providence, RI completed behavioral/psychosocial surveys at baseline, 6 months, and 12months. Generalized estimating equation modeling was used to examine the prospective relationship of additive psychosocial problems and subsequent CAS with male clients, adjusting for age, site, race/ethnicity, MSW-type, and HIV serostatus. RESULTS Mean age = 34.7 (SD = 11.8); 62% racial/ethnic minority; and 20% HIV+. The prevalence of 6 psychosocial syndemic problems was substantial at baseline and remained high at each time point (all within the past 6 months): 74% problematic depressive symptoms, 27% polydrug use (3+ drugs, not including stimulants), 57% stimulant (methamphetamine/cocaine/crack) use, 44% hazardous drinking, 15% experienced client-specific physical/sexual violence, and 57% childhood sexual abuse. Looking at the number of psychosocial problems experienced, 7% had zero, 27% had 1, 24% had 2, 27% had 3, and 15% had 4 or more. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial problems and CAS with male clients over time, with the greatest odds of engaging in CAS with a male client over follow-up among those with 4 or more psychosocial problems (adjusted odds ratio = 5.18, 95% CI: 1.61 to 16.62). CONCLUSIONS Internet escorts and street-based MSW are likely to experience psychosocial problems and engaging in HIV sexual risk with male clients. The accumulation of psychosocial problems additively predicted CAS with male clients in a prospective cohort of MSW. The specification of psychosocial problems presents distinct treatment targets for HIV prevention among MSW in the United States.

Historically, federal and state policies have narrowly defined treatment models that have resulted in limited access to and engagement in counseling for individuals receiving medications for opioid use disorder (MOUD; e.g., methadone and buprenorphine). In response to the coronavirus pandemic, outpatient MOUD treatment providers rapidly transitioned from traditional, in-person care delivery models to revised COVID-19 protocols that prioritized telehealth counseling to protect the health of patients and staff and ensure continuity in MOUD care. These telehealth innovations appear to mitigate many of the longstanding barriers to counseling in the traditional system and have the potential to forever alter MOUD care delivery. Drawing on data from a Rhode Island–based clinic, we argue that MOUD counseling is achievable via telehealth and outline the need for, and anticipated benefits of, hybrid telehealth/in-person MOUD treatment models moving forward., Highlights • The use of telehealth counseling for people on medications for opioid use disorder (MOUD) has increased during the pandemic • The use of telehealth for MOUD counseling has mitigated many of the longstanding barriers to care in the traditional system • In the post-COVID future, hybrid telehealth and in-person counseling models can improve treatment outcomes for people on MOUD

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression—all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18–29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18–29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum.

Background In recent years, Massachusetts (MA) and Rhode Island (RI) joined a growing list of states allowing residents to easily change the gender marker and name on government-identification (ID) documents. This was an important change for transgender and gender diverse (trans) residents, who face frequent mistreatment and thus for whom legal gender affirmation is critical. Little is known about associations between legal gender affirmation and psychological outcomes. Methods We examined associations between legal gender affirmation (i.e., having changed gender marker/name on neither, one, or both a passport and state ID), upsetting responses to gender-based mistreatment, and mental health outcomes in a sample of trans MA and RI residents. Analyses controlled for gender identity, age, race/ethnicity, education, employment, income, and insurance status. Findings Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment. Conclusions These data provide corroborate recent studies suggesting having pursued legal gender affirmation may be protective. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation., Highlights • About half of the sample reported changing name/gender marker in at least one of two government IDs. • Legal gender affirmation was associated with lower reports of upsetting responses to gender-based mistreatment. • Legal gender affirmation was associated with lower reports of depression, anxiety, somatization, psychiatric distress.

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.

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.

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.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.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.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.

Study/research objective To develop and validate a brief intimate partner violence (IPV) scale that screens for controlling behaviors and psychological abuse tactics directed toward transgender individuals. Rationale Transgender individuals are at elevated risk of physical and sexual IPV compared to cisgender individuals. IPV often takes on unique dimensions against transgender individuals, such as when an abusive partner threatens to "out" the transgender person, or use other tactics that weaponize transphobia within the relationship. Standard IPV screeners do not assess this type of transgender-specific IPV (T-IPV). Methods Between March 2018 and October 2019, a T-IPV scale was tested in two samples (in-person and online) of transfeminine adults (i.e. assigned a male sex at birth and identify with femininity) from the eastern and southern U.S. Exploratory factor analysis (EFA) was conducted with the in-person sample (N = 661) to assess construct validity. Confirmatory factor analysis (CFA) was then used in an independent online sample (N = 481). Using the combined sample (N = 1137), convergent validity was assessed using correlations with other forms of victimization. Multivariable regression models were fit to estimate the relationship between T-IPV and health outcomes. Results Factor analyses yielded an 8-item unidimensional scale with moderate to good fit. Nearly half the sample (48.7%) experienced at least one scale item. Internal consistency reliability was strong (KR-20 = 0.827). Significant correlations with other forms of victimization indicated convergent validity. Lifetime T-IPV was significantly associated with psychological distress (adjusted prevalence ratio [aPR] = 1.32, 95% CI = 1.13, 1.53), PTSD (aPR = 1.50, 95%CI = 1.31, 1.72), alcohol abuse (aPR = 1.21, 95%CI = 1.01, 1.44), and drug use disorder (aPR = 1.30, 95%CI = 1.06, 2.59). Conclusions This T-IPV scale is a reliable and unidimensional measure with strong construct validity. T-IPV is independently associated with mental health burden and substance use. Service providers working with transgender clients should screen for T-IPV to avoid missing cases of IPV, and refer to violence response services.

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.

Correctional healthcare providers' limited cultural and clinical competence to care for transgender patients represents a barrier to care for incarcerated transgender individuals.The present study aimed to adapt, deliver, and evaluate a transgender cultural and clinical competence intervention for correctional healthcare providers.In the summer of 2016, a theoretically-informed, group-based intervention to improve transgender cultural and clinical competence was delivered to 34 correctional healthcare providers in New England. A confidential survey assessed providers' cultural and clinical competence to care for transgender patients, self-efficacy to provide hormone therapy, subjective norms related to transgender care, and willingness to provide gender-affirming care to transgender patients before and after (immediately and 3-months) the intervention. Linear mixed effects regression models were fit to assess change in study outcomes over time. Qualitative exit interviews assessed feasibility and acceptability of the intervention.Providers' willingness to provide gender-affirming care improved immediately post-intervention (β = 0.38; SE = 0.41, p 0.001) and from baseline to 3-months post-intervention (β = 0.36; SE = 0.09; p 0.001; omnibus test of fixed effects χThe intervention increased correctional healthcare providers' cultural and clinical competence, self-efficacy, subjective norms, and willingness to provide gender-affirming care to transgender patients. Continued efforts should be made to train correctional healthcare providers in culturally and clinically competent gender-affirming care in order to improve the health of incarcerated transgender people. Future efficacy testing of this intervention is warranted.

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.

Purpose: The present study sought to examine whether individual (e.g., age, gender), interpersonal (e.g., healthcare provider discrimination), and structural (e.g., lack of insurance coverage) factors are associated with access to transition-related care in a statewide sample of transgender adults. Method: In 2013, 364 transgender residents of Massachusetts completed an electronic web-based survey online (87.1%) or in person (12.9%). A multivariable logistic regression model tested whether individual, interpersonal, and structural factors were associated with access to transition-related care. Results: Overall, 23.6% reported being unable to access transition-related care in the past 12 months. In a multivariable model, younger age, low income, low educational attainment, private insurance coverage, and healthcare discrimination were significantly associated with being unable to access transition-related care (all p

Background Despite the high prevalence of childhood sexual abuse (CSA) among men who have sex with men (MSM) and its well-documented association with substance use in adulthood, little research has examined the psychological mechanisms underlying this association. The current study utilized a large, multinational sample of MSM in Latin America to examine the role of distress intolerance (i.e., decreased capacity to withstand negative psychological states) in the relationship between childhood sexual abuse history and problematic alcohol use. Methods As part of an online survey conducted among members of the largest social/sexual networking website for MSM in Latin America, participants ( n = 19,451) completed measures of childhood sexual abuse history, distress intolerance, and problematic alcohol use (CAGE score > = 2). Results Participants who reported a history of childhood sexual abuse indicated higher levels of distress intolerance, which was in turn associated with greater odds of engaging in problematic alcohol use. A mediation analysis further showed that distress intolerance partially accounted for the significant association between childhood sexual abuse history and problematic alcohol use. Conclusion These findings provide initial evidence for the role of distress intolerance as a process through which early trauma shapes MSM health later in life. These findings also underscore the potential utility of addressing distress intolerance in alcohol use prevention and intervention efforts that target MSM with a history of childhood sexual abuse.

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.

To identify geographic and individual-level factors associated with healthcare access among transgender people in the United States.Multilevel analyses were conducted to investigate lifetime healthcare refusal using national data from 5831 U.S. transgender adults. Hierarchical generalized linear models examined associations between individual (age, gender, race, income, insurance, and healthcare avoidance) and state-level factors (percent voting Republican, percent same-sex couple households, income inequality, and transgender protective laws) and lifetime refusal of care.Results show that individual-level factors (being older; trans feminine; Native American, multiracial, or other racial/ethnic minority; having low income; and avoiding care due to discrimination) are positively associated with care refusal (all P-values0.05). Adjusting for individual-level factors, variation was observed across U.S. states, with a greater proportion of states in the Southern and Western United States with transgender residents at increased odds of experiencing care refusal, relative to other regions of the United States. When adjusting for state-level factors, the percentage of the state population voting Republican was positively associated with care refusal among the transgender adults sampled (P 0.01).Transgender adults surveyed reported differential access to healthcare by geographic region. Identifying geographic and individual-level factors associated with healthcare barriers allows for the development of targeted educational and policy interventions to improve healthcare access for transgender people most in need of services.

Objectives This study aims to identify factors associated with the reproductive planning of trans-masculine adults. Study design Between 2015 and 2016, providers enrolled 150 trans-masculine adults in a sexual health study assessing sociodemographics, social support, gender affirmation, sexual partnering, and reproductive history and planning. A brief clinical interview assessed contraceptive use and concerns. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and three outcomes: current contraceptive use, lifetime pregnancy history and reproductive planning. Results Overall, 37.3% are currently using contraceptives; 5.3% have been pregnant; and 20.0% plan to have biological children (9.3% plan to become pregnant; 12.0% plan to use their oocytes with a surrogate). Participants are less likely to use contraceptives if they are students vs. not, have socially affirmed their gender vs. not and have a partner vs. are single. Greater number of sexual partners is associated with the increased odds of contraceptive use. Further, as social support increases, the odds of having been pregnant decreases. Participants with a nonbinary gender identity are more likely to want to become pregnant than those with a binary gender identity, whereas those who have socially affirmed their gender are less likely to want to become pregnant than those who had not. Finally, participants of color more commonly planned to use their oocytes with a surrogate than white participants. Conclusion Sociodemographic, gender affirmation, social support and sexual partner factors are associated with contraceptive use and reproductive history among trans-masculine patients. Implications Healthcare providers must be aware of the diverse reproductive histories and pregnancy goals of trans-masculine individuals in order to provide comprehensive reproductive healthcare counseling and provision. More research is needed to better understand contraception and reproduction desires in trans-masculine individuals.

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.

Following publication of the original article [1], we have been notified of the below corrections.

Importance Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States. Objectives To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location. Design, Setting, and Participants This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination ofInternational Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location. Main Outcomes and Measures SUDDs, based onICD-10codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female). Results In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 664 [50.4%] female), most (8627 transgender adults [55.2%]; 25 882 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%];P Conclusions and Relevance In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.

Social–sexual networking technologies have been reported to yield both psychosocial benefits and sexual risks for gay and bisexual men, yet little research has explored how technology interacts with the social–geographical environment to shape the health of gay and bisexual men in the relatively understudied environment of small cities. This article draws on 29 semistructured interviews examining the use of social–sexual networking technologies among racially diverse gay and bisexual men in two small cities. Questions probed participants’ use of technology to meet sexual partners, engagement in the gay community, and the role of virtual and nonvirtual spaces in relation to health. Findings suggest that social networking technologies can help men navigate the challenges of small cities, including small and insular gay communities, lack of dedicated gay spaces, and sexual minority stigma. However, participants also describe declines in gay community visibility and cohesion, which they attribute to technology use. The article concludes by discussing the intersections of virtual and physical space in small cities as sites for the production of health and illness.

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 (β = 0.25; 95% CL [0.21, 0.30]) and greater number of attributed reasons for discrimination experiences (β = 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

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.

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time. Data Sources: MEDLINE, PsycINFO, and PubMed were searched for relevant studies from inception to November 2014. Reference lists of included studies were hand searched. Results: Three uncontrolled prospective cohort studies, enrolling 247 transgender adults (180 male-to-female [MTF], 67 female-to-male [FTM]) initiating hormone therapy for the treatment of gender identity disorder (prior diagnostic term for gender dysphoria), were identified. The studies measured exposure to hormone therapy and subsequent changes in mental health (e.g., depression, anxiety) and quality of life outcomes at follow-up. Two studies showed a significant improvement in psychological functioning at 3–6 months and 12 months compared with baseline after initiating hormone therapy. The third study showed improvements in quality of life outcomes 12 months after initiating hormone therapy for FTM and MTF participants; however, only MTF participants showed a statistically significant increase in general quality of life after initiating hormone therapy. Conclusions: Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning. Prospective controlled trials are needed to investigate the effects of hormone therapy on the mental health of transgender people.

Enacted and anticipated stigma exist within healthcare settings for transgender people, but research has yet to examine the effects of these forms of stigma on the substance use behaviors of female-to-male (FTM) trans masculine people.Data were analyzed from the cross-sectional U.S. National Transgender Discrimination Survey, a convenience sample of transgender adults purposively sampled in 2008. Trans masculine respondents (n=2,578) were identified using a two-step method: Step 1, Assigned birth sex; Step 2, Current gender identity. A gender minority stress model of substance use was tested to examine the relation of enacted and anticipated stigma with substance use to cope with mistreatment.Overall, 14.1% of the sample reported having been refused care by a provider (enacted stigma), 32.8% reported delaying needed medical care when sick/injured, and 39.1% delayed routine preventive care (anticipated stigma). Having been refused care was significantly associated with avoidance of healthcare, including delaying needed medical care when sick/injured and delaying routine preventive medical care. Substance use to cope with mistreatment was self-reported by 27.6% of the sample. Enacted stigma by providers was associated with self-reported substance use to cope. Delays in both needed and preventive care (anticipated stigma) were highly associated with substance use, and attenuated the effect of enacted stigma.Gender minority-related stressors, particularly enacted and anticipated stigma in healthcare, should be integrated into substance use and abuse prevention and intervention efforts with this underserved population.

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.