A Three Paper Examination of Social Inequity and Health and Illness among Transwomen

Transwomen are among the most vulnerable populations in the United States and are disproportionately at risk for HIV and other negative health outcomes. Research with transwomen has been largely descriptive, documenting the high prevalence of various co-morbidities, ranging from substance use to negative mental health outcomes. In these studies, singular axes of identity have generally been analyzed. For example, studies have found that race is especially salient in the health of transwomen, finding that transwomen of color experience numerous structural inequalities that drive disparities in health. More intersectional research to examine social inequities in health and illness among transwomen is needed to better understand factors situated in the lived experiences of transwomen. This dissertation draws upon quantitative methods to examine disparities in HIV risk behavior and substance use among transwomen at the intersection of race and gender (Paper 1) and sexuality and gender (Paper 2). Qualitatively, this dissertation examines transmisogyny as a form of intersectional stress among transwomen (Paper 3). This first study is a cross-sectional analysis of data from a sample of 149 HIV-negative adult transwomen in San Francisco collected in 2013 from the TEACH 2 study. The second study is a cross-sectional analysis of data from a sample of 259 young transwomen in the San Francisco Bay Area collected in 2012-2014 from the SHINE study. The third study is a secondary analysis of qualitative, in-depth interview data from the Transgender Research Youth Project (TRYP), collected from 34 young transwomen in Chicago and Los Angeles in 2006. Altogether, these studies argue that future transgender research should increasingly take up intersectionality in order to understand the unique social location of transwomen

Brief Report

BackgroundTrans*female youth (TFY) carry a disproportionate burden of HIV. Few longitudinal studies have analyzed both proximal and upstream predictors of changes in HIV-related risk behaviors for TFY. The aim of the present analysis was to identify psychosocial predictors of changes in sexual risk behavior over time for TFY in the San Francisco Bay Area.MethodsData come from the SHINE cohort study conducted at the San Francisco Department of Public Health from 2012 to 2014 (n = 263). The relationship between hypothesized psychosocial factors and changes in engagement in condomless receptive anal intercourse over 12-month follow-up was modeled using generalized estimating equations, after adjusting for participant age, race/ethnicity, and education level.ResultsTFY who were ever in a serious relationship since identifying as trans* [adjusted odds ratio (aOR) = 1.89, 95% confidence interval (CI): 1.16 to 3.08], those who reported recent crack/cocaine use (aOR = 2.01, 95% CI: 1.05 to 3.85), and those with a monthly income of more than $500 (aOR = 0.55, 95% CI: 0.35 to 0.85) had significantly higher odds of condomless receptive anal intercourse over the 12-month study period compared to TFY without these exposures. Those who reported high exposure to gender-based discrimination had increased adjusted odds of engagement in condomless receptive anal intercourse compared to those who had low exposure over the study period (aOR = 1.70, 95% CI: 1.10 to 2.63).ConclusionsBoth proximal and structural factors predicted increased engagement in sexual risk behavior among TFY. Results demonstrate the need for a multilevel approach to HIV prevention strategies for this population

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California

Abstract Background Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades. Methods Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher’s exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades. Results Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049). Conclusions We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women. Trial registration NCT, NCT 21–34,978. Registered January 19, 2022

Parent/Caregiver Responses to Gender Identity Associated With HIV-Related Sexual Risk Behavior Among Young Trans Women in San Francisco

PurposeYoung trans women (YTW) carry a disproportionate burden of HIV. The developmental context of HIV risk for YTW is underexamined. The aim of this analysis was to examine whether parent/caregiver responses to gender identity were associated with engagement in HIV-related sexual risk behavior for YTW and whether these associations varied by racial/ethnic identity or age.MethodsBaseline data from the SHINE study (n = 300) at San Francisco Department of Public Health (2012-2014) were analyzed. Multivariable Poisson binomial regression models characterized relationships between parent/caregiver responses to gender identity and HIV-related sexual risk behaviors, adjusting for select participant demographics. Statistically significant interactions (by race/ethnicity or age) were plotted using marginal predicted probabilities of sexual risk behaviors.ResultsThirty-seven percent of YTW engaged in any condomless anal intercourse; 12% reported income from sex work in the last month. Ever moving away from family and friends because of gender identity was associated with condomless anal intercourse (adjusted prevalence ratio [PR] = 1.44, 95% confidence interval [CI] = 1.08-1.92, p = .01) and sex work (PR = 2.07, 95% CI = 1.14-3.75, p=.02). Ever receiving poor treatment from parents/caregivers because of gender identity was associated with sex work (PR = 3.47, 95% CI = 1.52-7.95, p < .01). Greater parent/caregiver acceptance of gender identity was associated with lower adjusted prevalence of condomless anal intercourse for Hispanic/Latinx YTW.ConclusionsNegative parent/caregiver exposures related to YTW's gender identities were associated with increased HIV-related sexual risk behaviors, whereas parent/caregiver acceptance of gender identity was protective against condomless anal intercourse for Hispanic/Latinx YTW. There is a need for additional studies that inform interventions for YTW focusing on parent/caregiver relationships to prevent HIV-related risk behavior

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

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system

Disparities in the PrEP continuum for trans women compared to MSM in San Francisco, California: results from population‐based cross‐sectional behavioural surveillance studies

IntroductionAlthough transgender women (trans women) often are conflated with men who have sex with men  (MSM) in HIV research and services, there are distinct population differences that are important for implementing effective HIV prevention. Our objective was to examine pre-exposure prophylaxis (PrEP) disparities between the two populations and compare individual, social and structural factors that influence differences between MSM and trans women along the PrEP continuum.MethodsWe analysed data from two population-based studies, one with trans women (Trans*National Study, 2016 - 18) and the other with MSM (National HIV Behavioral Surveillance, 2017). Trans women were recruited via respondent-driven sampling and MSM using time location sampling. Key indicators of the PrEP continuum were evaluated, including awareness, health insurance, provider discussions, recent use and adherence. Associations were also examined for PrEP continuum indicators and structural barriers (e.g. employment, homelessness).ResultsTranswomen were more likely than MSM to be Latino/a (30.4% vs. 25.8%; prevalence ratio (PR)=1.08, 95% CI 1.02 to 1.14) or African American (7.1% vs. 4.5%; PR = 1.12, 1.02 to 1.24), live at or below the poverty limit (70.7% vs. 15.8%; PR = 1.47; 1.41 to 1.53), be unemployed (50.1% vs. 26.3%; PR = 1.18, 1.13 to 1.24), be homeless (8.4% vs. 3.5%; PR = 1.15, 1.06 to 1.25) and to have less than a college degree (PR = 1.41, 1.34 to 1.48). Trans women were more likely than MSM to have health insurance (95.7% vs. 89.7%, PR = 1.17, 1.06 to 1.28), but less likely than MSM to have heard of PrEP (79.1% vs. 96.7%; PR = 0.77, 0.73 to 0.81), talked with a provider about PrEP (35.5% vs. 54.9%; PR = 0.87, 0.83 to 0.91) and less likely than MSM to have used PrEP in the past six months (14.6% vs. 39.8%; PR = 0.80, 0.76 to 0.84). Among PrEP users, trans women were less likely to report being adherent to PrEP than MSM (70.4% vs. 87.4%; PR = 0.80, 0.70 to 0.91).ConclusionsWe found PrEP disparities for trans women compared to MSM and the need for differentiated implementation strategies to meet the specific PrEP barriers trans women face. Inclusion of trans women's HIV risks is needed in CDC guidance for PrEP. Interventions to increase trans women's awareness of PrEP including at the provider and community level are also needed. Finally, programming that addresses trans women's barriers to housing and income is also needed to reduce PrEP disparities

A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care.

BackgroundTo determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community.MethodsInterviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman.ResultsViolence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016.ConclusionOur findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization

Stigma as a barrier and sex work as a protective factor for HIV testing among trans women in Nepal.

Stigma towards trans women in Nepal creates individual and system-level risks for HIV. A critical protective factor is access to HIV prevention. Research is needed to determine the impact of stigma on HIV testing among trans women in Nepal. We conducted a secondary analysis of data collected using respondent driven sampling in 2019 on HIV risk among trans women in Nepal. Data analysis was restricted to trans women who were HIV negative at testing through the parent study. Descriptive statistics, tests for bivariable associations between HIV testing and stigma variables, and binomial Poisson regression were conducted to examine HIV testing outcomes. There were 173 participants who tested negative for HIV in our sample. The majority were under age 35 (59%) and most had a grade school education or less (64.7%). No trans women were homeless and most rented a room (70.5%) or owned their home (19.7%). The majority were currently sex workers (57.8%). Almost all HIV-negative trans women had ever been tested for HIV (90.8%), but only 53.5% in the last 3 months. The most frequently cited reason for not having been tested was thinking they were at low risk for HIV (40.9%) and being afraid of receiving a positive test result (22.7%). HIV and anti-trans stigma were high across most measures, including that almost all (94.2%) believed that most people in Nepal would discriminate against people with HIV. And most participants thought trans women were not accepted in Nepali Society (65.9%). Most participants also reported high social support (70.5%). Social cohesion among participants varied, with most experiencing medium (41.6%) or high (33.5%) social cohesion. Just over half had high social participation (55.5%). Participants who reported current sex work had lower prevalence of not testing for HIV in the last 3 months (prevalence ratio, PR = 0.54, 95% confidence interval, 95%CI = 0.32-0.92, p = 0.02). Every one-unit increase in social cohesion was associated with 1.05 times the prevalence of not testing for HIV in the last 3 months (95%CI = 1.01-1.09, p-value = 0.02). Trans women who did sex work were more likely to be HIV tested while those who were more socially connected to peers were less likely to have recently been tested for HIV. HIV stigma may result in fear of social rejection from peers if one tests positive. Interventions that focus on addressing stigma within trans women's social networks and strategies to mitigate HIV stigma in society may result in increased frequency of HIV testing among trans women in Nepal

Experiences and factors associated with transphobic hate crimes among transgender women in the San Francisco Bay Area: comparisons across race.

BACKGROUND: Trans women experience high rates of gender-based violence (GBV)-a risk factor for adverse health outcomes. Transphobic hate crimes are one such form of GBV that affect trans women. However, little is understood about factors that shape transphobic hate crimes and racial/ethnic variation in these experiences. To contextualize GBV risk and police reporting, we examined self-reported types and correlates of transphobic hate crimes by racial/ethnic group of trans women in the San Francisco Bay Area. METHODS: From 2016 to 2018, trans women participated in a longitudinal cohort study of HIV. Secondary data analyses (N = 629) examined self-reported experiences of transphobic hate crimes (i.e., robbery, physical assault, sexual assault, and battery with weapon) by race/ethnicity, and whether hate crimes were reported to the police. Chi-square tests and simple logistic regression examined demographic, sociocultural, and gender identity factors associated with transphobic violence experiences and police reporting. RESULTS: About half (45.8%) of participants reported ever experiencing a transphobic hate crime; only 51.1% of these were reported to the police. Among those who reported a hate crime experience, Black (47.9%) and Latina (49.0%) trans women reported a higher prevalence of battery with a weapon; White (26.7%) and trans women of other race/ethnicities (25.0%) reported a higher prevalence of sexual assault (p = 0.001). Having ones gender questioned, history of sex work, homelessness as a child and adult, and a history incarceration were associated with higher odds of experiencing a transphobic hate crime. Trans women who felt their gender identity questioned had lower odds of reporting a hate crime to the police compared to those did not feel questioned. CONCLUSIONS: A high proportion of trans women experienced a transphobic hate crime, with significant socio-structural risk factors and racial differences by crime type. However, crimes were underreported to the police. Interventions that address structural factors, especially among trans women of color, can yield violence prevention benefits