Sex work, social support, and stigma: Experiences of transgender women in the Dominican Republic

Stigmas experienced by sexual and gender minority people with HIV in the Dominican Republic: a qualitative study

BACKGROUND

As part of a study to test the feasibility and acceptability of the Finding Respect and Ending Stigma around HIV (FRESH) intervention to reduce stigmas and improve HIV viral suppression, our team collected qualitative data from men who have sex with men (MSM) with HIV, transgender women with HIV, and HIV healthcare providers for their perspectives on different stigmas in Dominican Republic healthcare settings.

PURPOSE

We aimed to develop an understanding of the causes, consequences, and domains of stigma among sexual and gender minorities with HIV in Dominican Republic HIV clinics.

METHODS

Data collection occurred in Santo Domingo and Santiago (2020-2021) and included four focus groups with MSM with HIV (n = 26), in-depth interviews with transgender women with HIV (n = 14), and in-depth interviews with HIV healthcare providers (n = 16). All data collection occurred in person and was audio recorded. Standardized guides were used for focus groups and in-depth interviews. Using a deductive process, 2 research associates thematically coded data in the NVivo software.

RESULTS

On average, focus groups were 81 minutes, provider in-depth interviews were 24 minutes, and transgender women in-depth interviews were 32 minutes. We identified 4 key themes that mapped to 4 domains of stigma affecting MSM and transgender women with HIV: migrant stigma, religious stigma, sexual and gender minorities (SGM) stigma, and HIV stigma. All participant types noted the persistence of stigma and discrimination in healthcare settings in the Dominican Republic. The consequences of these stigmas were reported as being significant, including attempted suicide.

CONCLUSIONS

Interventions to reduce stigma experienced by SGM populations with HIV should address structural barriers, including inner and outer contexts of HIV care provision and cultural norms and values that propagate stigma. Findings offer insights about which stigmas could be targeted in future studies and how to potentially address stigma to improve population health in the Dominican Republic.

Correlates of HIV Testing Among Asian Immigrant Female Sex Workers in New York City and Los Angeles County

This analysis examined correlates of HIV testing among Asian immigrant female sex workers in massage parlors. We interviewed 69 Chinese and Korean immigrant women who provided sexual services in massage parlors in New York City or Los Angeles County (2014-2016). Multivariable logistic regression results showed that participants who were younger, have lived in the U.S. for a longer period of time, had greater English proficiency, perceived higher HIV risk, or were living with an intimate partner were more likely to have had an HIV test. Disclosing sex work to a close friend was also positively associated with HIV testing at p < .1. These correlates may reflect differential access to information, systems, and social networks that would facilitate HIV testing, highlighting the importance of reducing social isolation and increasing HIV education, especially for older women who have come to the U.S. more recently. As the literature has indicated that Asian immigrant female sex workers experience high rates of intersectional stigma, efforts to mitigate these intersecting stigmas could further these objectives.

Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

Transgender Women Experiencing Homelessness - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Transgender women experience high prevalence of homelessness, which can affect their likelihood of acquiring HIV infection and can lead to poor medical outcomes. CDC analyzed data from the National HIV Behavioral Surveillance Among Transgender Women to identify whether personal characteristics and social factors affecting transgender women were associated with duration of homelessness during the past 12 months. Longer duration and chronic homelessness might indicate greater unmet needs, which increases their likelihood for acquiring HIV infection. Ordinal logistic regression was conducted to calculate adjusted prevalence odds ratios and 95% CIs for transgender women from seven urban areas in the United States experiencing homelessness 30-365 nights, 1-29 nights, and zero nights during the past 12 months. Among 1,566 transgender women, 9% reported 1-29 nights homeless and 31% reported 30-365 nights homeless during the past 12 months. Among participants who reported physical intimate partner violence or forced sex, 50% and 47%, respectively, reported experiencing 30-365 nights homeless. Furthermore, 55% who had been evicted or denied housing because of their gender identity and 58% who had been incarcerated during the past year experienced 30-365 nights homeless. The odds of transgender women experiencing longer duration of homelessness was associated with being younger and having a disability; higher psychological distress scores were associated with longer duration of homelessness. Analysis of social determinants of health found transgender women experiencing longer homelessness to be less educated, living below the Federal poverty level, and having lower social support. Therefore, focusing on HIV prevention and interventions addressing housing instability to reduce the duration of homelessness among transgender women is important. Further, integrating housing services with behavioral health services and clinical care, specifically designed for transgender women, could reduce HIV acquisition risk and improve HIV infection outcomes.

Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic

Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.

Beyond a deficit-based approach: Characterizing typologies of assets for cisgender and transgender female sex workers and their relationship with syndemic health outcomes

Female sex workers (FSWs) live and work at the intersection of multiple marginalized identities that place them at greater risk for various negative health outcomes. Resilience theory asserts that an individual or community needs assets from which they can draw in response to stressors, such as chronic discrimination and abuse. This study characterizes and compares patterns of assets among cisgender and transgender FSWs living with HIV in the Dominican Republic and their relations with syndemic health outcomes. With Latent Class Analysis, we used companion cross-sectional datasets comprised of cisgender and transgender FSWs (N = 211 and 100, respectively) to estimate typologies of interpersonal, community, and institutional assets. We used multivariate logistic regression to model the relationship between class membership and HIV care and treatment, mental health, violence exposure, and substance use outcomes, respectively. Among cisgender FSWs, we identified three classes: Internal and External Multilevel Assets (Class 1); External Institutional Assets (Class 2); and Low Reported Assets (Class 3). Compared to Class 3, Class 1 membership among cisgender FSWs was significantly associated with ART adherence and marginally associated with viral suppression, and Class 2 membership was marginally associated with currently taking ART. We identified two classes in the transgender sample: Internal and External Multilevel Assets (Class 1) and External Institutional Assets (Class 2). Class 1 membership among transgender FSWs was significantly associated with ART adherence and marginally associated with current ART use and physical or sexual violence, compared to Class 2. Having a variety of assets may explain the ability of some FSWs to more effectively engage with healthcare and maintain their HIV medication regimen. Future interventions should seek to expand FSWs' interpersonal and community assets, both from within and outside of the sex worker community, to bolster their ability to care for themselves and their community.

Stigma and HIV Treatment Outcomes Among Transgender Women Sex Workers in the Dominican Republic

Trans women experience multiple forms of intersecting stigma due to trans identity, HIV, and sex work, which can negatively affect their health. There is limited understanding of the relationships between stigma and HIV care and treatment outcomes. We assessed associations between multiple forms and types of stigma and HIV treatment outcomes among trans women who conduct sex work in Santo Domingo, Dominican Republic using cross-sectional survey data. Most participants had received HIV care (91%) and were currently taking anti-retroviral therapy (ART) (84%). Only 64% were virally suppressed. Nearly one-third (32%) had interrupted ART at some point; those who had never interrupted ART were more likely to be suppressed. Drug use was associated with ART interruption. Higher enacted HIV stigma was associated with current ART use. Higher enacted HIV stigma and higher anticipated sex work stigma were associated with ART adherence. Higher trans stigma was associated with being virally suppressed. Findings highlight the importance of addressing multiple forms of stigma at the individual and clinic levels to improve and sustain viral suppression. Future research is needed to assess if unexpected associations between stigma and HIV outcomes reflect processes of resilience. Future research is also needed to assess the pathways between drug use, ART interruption, and viral suppression among trans women.

The factors influencing the psychological distress of transgender women in Shandong, China: a cross-sectional study

Background

As a group at high-risk for acquired immune deficiency syndrome (AIDS) infection, the psychological distress of transgender women cannot be ignored while preventing and controlling AIDS risks. Transgender women are a vulnerable group, and their psychological distress deserves attention. The purpose of this study was to evaluate the psychological distress of transgender women and further determine the influences of factors on the psychological distress of transgender women.

Methods

From March 2021 to August 2021, a cross-sectional survey was conducted in Shandong province, China. Data were collected by a questionnaire designed for transgender women, and the GHQ-12 scale was used to measure their psychological distress. The questionnaire combined sociodemographic characteristics, HIV/AIDS cognition, related behaviors, substance abuse, social support, gender identity and other factors. Univariate logistic regression and multivariate logistic regression models were used to explore the psychological factors of transgender women.

Results

In this study, the rate of transgender women with psychological distress was 20.08%. Earned monthly income between 10,000–15,000 yuan (OR:0.16, 95% CI:0.06–0.45) and a monthly income greater than 15,000 yuan (OR:0.07, 95% CI:0.01–0.43) were protective factors in the psychology of transgender women. Transgender women who never disclosed sexual orientation and identity (OR: 0.19, 95% CI: 0.06–0.58), who only disclosed their sexual orientation and identity to families or friends (OR: 0.41, 95% CI: 0.18–0.93) were also less likely to have psychological distress. Additionally, transgender women who did not desire to be identified with their sexual orientation and identity (OR: 3.31, 95%CI: 1.08–10.16) and who reported that the Internet did not play an essential role in helping determine sexual orientation (OR: 5.96, 95% CI: 2.91–12.20) were more likely to have psychological distress.

Conclusion

Transgender women were at risk of psychological distress. Earning more money can help transgender women's psychological health. When formulating measures for transgender women, we should pay attention to enhance social inclusion and social acceptance of their gender identity and sexual orientation. Strengthening the role of the internet in transgender women's confirmation of sexual orientation and improving the social acceptance of transgender women will have a positive impact on the psychological status of transgender women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13357-9.

"If They Give Their Mind to HIV, They Don't Last as Long": An Explanatory Model of HIV Infection in a Limited-Resource Setting Informs Person-Centered Care

Explanatory models describe individuals' perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman's explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman's framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients' illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

Transgender Women in Dominican Republic: HIV, Stigma, Substances, and Sex Work

Exposure to stigma, violence, sex work, and substance use are associated with increased HIV risk, but relationships between these factors have not been fully elucidated among transgender women whose data are often aggregated with men who have sex with men and other sexual and gender minorities. Considering this gap, we aimed to identify a serologically confirmed HIV estimate for transgender women and examine the relationships between stigma, sex work, substance use, and HIV among a national sample of transgender women in Dominican Republic. We analyzed biomarkers and self-report data from the third wave of Dominican Republic's Encuesta de Vigilancia y Comportamiento con Vinculación Serológica, employing logistic and negative binomial regression to estimate models (n = 307). HIV rate was 35.8%. Nearly 75% of respondents engaged in sex work. Over 20% reported experiencing violence; 61.6% reported being stigmatized. Participation in sex work was associated with higher levels of stigma [incidence rate ratio (IRR): 1.70, p < 0.05]. Respondents who experienced violence had over three times higher odds of living with HIV relative to respondents who had not been victimized [odds ratio (OR): 3.15, p < 0.05]. Marijuana users were less likely to experience stigma compared with cocaine users (IRR: 1.72, p < 0.05), and a higher risk of alcohol dependency was associated with higher odds of experiencing violence (OR: 1.17, p < 0.001). Findings illustrate the importance of disaggregating data collected from transgender women compared with other sexual and gender minorities to ascertain subpopulation-specific estimates and indicate an urgent need to implement structural interventions and policies to protect transgender women's health and their human rights.

Stigma, Social Cohesion, and Mental Health Among Transgender Women Sex Workers Living with HIV in the Dominican Republic

Globally, transgender (trans) women experience pervasive stigma, which contributes to health inequities across multiple mental health outcomes. While trans stigma has been associated with increased mental health challenges, less is known about how stigma related to sex work and HIV affect mental health. Social cohesion may ameliorate the negative health consequences of stigma, but little is known about how social cohesion is associated with mental health among trans women. Using cross-sectional survey data collected in 2019 among 100 trans women sex workers living with HIV in Santo Domingo, Dominican Republic, we examined associations between stigma (related to HIV, sex work, and trans identity), social cohesion, and depression and anxiety symptoms. In unadjusted models, enacted and internalized sex work stigma were associated with greater odds of depression and anxiety symptoms and social cohesion was associated with less depression and anxiety. Resisted sex work stigma, which captured acceptance of self and work, was associated with lower odds of depression and trans stigma was associated with increased anxiety. In adjusted models, internalized sex work stigma was associated with increased depression (aOR=1.19, p=0.018) and anxiety symptoms (aOR=1.12, p=0.021), while social cohesion was associated with reduced depression (OR=0.81, p=0.002) and anxiety symptoms (aOR=0.086, p=0.023). Findings indicate the need for interventions to focus on reducing internalized sex work stigma and promoting social cohesion to improve mental health among trans women. Additional research is needed to determine how to best measure the intersections between HIV, sex work, and trans stigma and their impact on mental health.

Female Sex Workers' Experiences of Violence and Substance Use on the Haitian, Dominican Republic Border

Background

Female sex workers (FSW) are socially and economically marginalized, and this vulnerability can be exacerbated when they hold the intersectional identity of also being an immigrant, such as in the case of Haitian FSWs in the Dominican Republic.

Objective

Considering that half of migratory young women and girls relocating across the Latin American and Caribbean region do so without their families, increasing the likelihood of experiencing abuses, our primary objective was to test the hypothesis that Haitian FSWs in the Dominican Republic have higher odds of being physically abused by sexual partners compared to Haitian FSWs in Haiti.

Methods

We conducted bivariate analyses and multivariate analyses on 2014 Hispaniola Sex Workers Study (N = 232).

Findings

Approximately 80% of Haitian FSWs in the Dominican Republic reported experiencing violence by a regular partner (80.3%), compared with 60.0% of Haitian FSWs in Haiti (χ2 = 11.34, p < 0.001). Controlling for socio-demographics, substance use, childhood abuse, and sexual behaviors, Haitian FSWs in Haiti maintained lower odds of experiencing violence by a regular partner (OR:0.37, p < 0.01) and higher odds of experiencing violence from a coworker (OR:6.38, p < 0.001) compared to FSWs in the Dominican Republic. Using sex to avoid arrest is associated with higher odds of experiencing violence by a client and violence by a coworker (OR:2.18, p < 0.05; OR:3.74, p < 0.001; respectively). Accepting payment in the form of drugs/alcohol is associated with higher odds of experiencing physical violence by a regular partner but lower odds of experiencing violence by a client (OR:3.99, p < 0.05; OR:0.43, p < 0.05; respectively).

Conclusions

Assuming health is a human right, then practitioners and scholars must actively collaborate to fortify vulnerable populations against injurious structural and sociocultural forces examining the intersectionality and compound effects of multiple stigmatized identities, in this study being an FSW and an immigrant, that moderate the potential positive effects of public health interventions.