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Cheung AS, Zwickl S, Miller K, Nolan BJ, Wong AFQ, Jones P, Eynon N. The Impact of Gender-Affirming Hormone Therapy on Physical Performance. J Clin Endocrinol Metab 2024; 109:e455-e465. [PMID: 37437247 PMCID: PMC10795902 DOI: 10.1210/clinem/dgad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance. EVIDENCE ACQUISITION MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes. EVIDENCE SYNTHESIS Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women. CONCLUSION Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | | | - Brendan J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Alex Fang Qi Wong
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
- Australian Regenerative Medicine Institute, Monash University, Clayton 3800, Australia
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2
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Cheung AS, Nolan BJ, Zwickl S. Transgender health and the impact of aging and menopause. Climacteric 2023; 26:256-262. [PMID: 37011669 DOI: 10.1080/13697137.2023.2176217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Gender affirming hormone therapy (GAHT) is used by many transgender people to reduce gender incongruence and improve psychological functioning. As GAHT shares many similarities with menopausal hormone therapy, clinicians supporting people through menopause are ideally placed to manage GAHT. This narrative review provides an overview of transgender health and discusses long-term effects of GAHT to consider when managing transgender individuals across the lifespan. Menopause is less relevant for transgender individuals who take GAHT (often given lifelong) to achieve sex steroid concentrations generally in the range of the affirmed gender. For people using feminizing hormone therapy, there is an elevated risk of venous thromboembolism, myocardial infarction, stroke and osteoporosis relative to cisgender individuals. For trans people using masculinizing hormone therapy, there is an increased risk of polycythemia, probable higher risk of myocardial infarction and pelvic pain which is poorly understood. Proactive mitigation of cardiovascular risk factors is important for all transgender people and optimization of bone health is important for those using feminizing hormones. With a lack of research to guide GAHT in older age, a shared decision-making approach is recommended for the provision of GAHT to achieve individual goals whilst minimizing potential adverse effects.
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Affiliation(s)
- A S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - B J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - S Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
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3
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Longstreth GF, Attix C, Kuck J. Torture Survivors and Asylum: Legal, Medical, and Psychological Perspectives. Am J Med 2023; 136:244-251. [PMID: 36370801 DOI: 10.1016/j.amjmed.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022]
Abstract
Torture occurs worldwide. Survivors seeking asylum are detained and must complete a complicated legal process to prove a "well-founded fear of persecution" if returned to their home countries. Forensic evaluations guided by the United Nations Istanbul Protocol increase asylum grant rates. Medical evaluation emphasizes skin examination, which can provide strong evidence of torture. Female genital mutilation and cutting, a basis for asylum, is classified according to the World Health Organization. Many resettled refugees and foreign-born immigrants at urban health care facilities have been tortured, but few report it to physicians due to factors affecting both survivors and physicians. Specific torture methods can cause characteristic long-term sequelae. Painful somatic disorders of mind-body interaction and psychological disorders are common. Practices derived from cultural factors and traumatized individuals' feedback enhance management of survivors. Individual and group psychotherapy provide modest proven benefit, but assessment is limited. Physicians and psychotherapists should coordinate care.
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Affiliation(s)
- George F Longstreth
- Survivors of Torture International, San Diego, Calif; Veterans Administration San Diego Healthcare System, San Diego, Calif.
| | | | - Julie Kuck
- Survivors of Torture International, San Diego, Calif
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4
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Allison SM, Parker KL, Senn TE. Incorporating a trauma-informed perspective in HIV-related research with transgender and gender diverse individuals. J Int AIDS Soc 2022; 25 Suppl 5:e25976. [PMID: 36225137 PMCID: PMC9557012 DOI: 10.1002/jia2.25976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/30/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Susannah M. Allison
- National Institute of Mental HealthNational Institutes of HealthRockvilleMarylandUSA
| | - Karen L. Parker
- Sexual and Gender Minority Research OfficeNational Institutes of HealthRockvilleMarylandUSA
| | - Theresa E. Senn
- National Institute of Mental HealthNational Institutes of HealthRockvilleMarylandUSA
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5
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Budhwani H, Paulino-Ramírez R, Waters J, Bond CL, Ruiz I, Long DM, Varas-Díaz N, Naar S, Nyblade L, Turan JM. Adapting and pilot testing an HIV and intersectional stigma reducing intervention for Dominican Republic healthcare contexts: Protocol for translational research. Contemp Clin Trials Commun 2022; 29:100980. [PMID: 36060154 PMCID: PMC9434029 DOI: 10.1016/j.conctc.2022.100980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/22/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background This protocol details the adaptation and pilot testing of the Finding Respect and Ending Stigma around HIV (FRESH) intervention in Dominican Republic. FRESH is a healthcare setting stigma-reduction intervention designed to reduce stigmas affecting people living with HIV (PLHIV), focusing on HIV and intersectional stigmas experienced by sexual and gender minority (SGM) people living with HIV. After the successful adaptation of the FRESH intervention, it will be pilot-tested through the conduct of a pilot stepped wedge cluster randomized controlled trial. Methods Three aims are included in this study; Aim 1 includes exploratory qualitative assessment, specifically the conduct four focus groups with men who have sex with men (MSM) living with HIV (n = 24-32) and in-depth interviews with transgender women living with HIV to explore their experiences with stigma in clinics (n = 9-12). In-depth interviews will also be held with HIV healthcare workers to elucidate their perceptions and behaviors towards their SGM clients (n = 9-12). In Aim 2, informed by Aim 1 data, we will use the sequential phases of the ADAPT-ITT framework to iteratively adapt the FRESH intervention for the Dominican Republic. In Aim 3, the adapted intervention will be pilot-tested via a cluster stepped wedge randomized controlled trial to assess feasibility and acceptability of the intervention and study protocols. Conclusions If this pilot trial is successful, next steps will include testing the adapted intervention across Dominican Republic or in similar Spanish-speaking Caribbean nations in a larger trial to assess effectiveness in reducing stigma in clinical settings towards PLHIV.
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Affiliation(s)
- Henna Budhwani
- Florida State University, College of Nursing, Center of Population Sciences for Health Equity, Tallahassee, FL, United States
- Corresponding author. Florida State University, College of Nursing, Center of Population Sciences for Health Equity, 2010 Levy Avenue, Building B, Suite 3600, Tallahassee, FL, 32306, United States.
| | | | - John Waters
- Caribbean Vulnerable Communities Coalition (CVC), Kingston, Jamaica
| | - Christyenne L. Bond
- Florida State University, College of Nursing, Center of Population Sciences for Health Equity, Tallahassee, FL, United States
| | - Ingrid Ruiz
- Universidad Iberoamericana (UNIBE), Santo Domingo, Dominican Republic
| | - Dustin M. Long
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States
| | - Nelson Varas-Díaz
- Florida International University, Department of Global and Sociocultural Studies, Miami, FL, United States
| | - Sylvie Naar
- Florida State University, Department of Behavioral Sciences and Social Medicine, Tallahassee, FL, United States
| | - Laura Nyblade
- Research Triangle Institute (RTI) International, Research Triangle Park, NC, United States
| | - Janet M. Turan
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States
- Koç University, School of Medicine, Istanbul, Turkey
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6
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Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, Frau I, Murgia R, El Kacemi S, Galeazzi GM, Mirandola M, Amaddeo F, Crapanzano A, Converti M, Piras P, Suprani F, Manchia M, Fiorillo A, Carpiniello B. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry 2022; 34:292-359. [PMID: 36151828 DOI: 10.1080/09540261.2022.2093629] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.
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Affiliation(s)
- Federica Pinna
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Pasquale Paribello
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Giulia Somaini
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Alice Corona
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Antonio Ventriglio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Carolina Corrias
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Ilaria Frau
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Roberto Murgia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Sabrina El Kacemi
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Gian Maria Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Dipartimento ad attività integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Mirandola
- Department of Diagnostics and Public Health, Infectious Diseases Section, University of Verona, Verona, Italy.,School of Sport and Health Sciences, University of Brighton, Brighton, UK
| | - Francesco Amaddeo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Crapanzano
- Department of Counseling, San Francisco State University, San Francisco, California, USA
| | - Manlio Converti
- Dipartimento di salute mentale, ASL Napoli 2 Nord, Naples, Italy
| | - Paola Piras
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Federico Suprani
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy.,Department of Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Bernardo Carpiniello
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
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7
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Campbell MH, Gromer J, Emmanuel MK, Harvey A. Attitudes Toward Transgender People Among Future Caribbean Doctors. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:1903-1911. [PMID: 34782942 DOI: 10.1007/s10508-021-02205-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
The attitudes of medical students toward transgender people have important implications for the future quality of healthcare for Caribbean transgender patients. This paper examined the attitudes and beliefs of Caribbean medical students toward transgender people, provides psychometric evaluation of a promising instrument, and considers implications for the development of transgender curricula in Caribbean medical education. Medical students (N = 205; 155 women, 43 men, 7 unstated) enrolled at a publicly supported Caribbean university completed the Transgender Attitudes and Beliefs Scale (TABS; Kanamori et al., 2017). Internal consistency was strong for the total TABS (α = .93) and more variable for the three subscales: interpersonal comfort (IC: α = .91), sex/gender beliefs (SGB: α = .89), and human value (HV: α = .74). Confirmatory factor analysis demonstrated acceptable overall fit for the three-factor model. There were no significant gender differences in overall attitudes toward transgender people as measured by the total TABS score; women reported higher IC scores. Scores were not correlated with age or with year in medical school. Students reported significantly more tolerant attitudes on the HV scale than on IC or SGB scales. Psychometric findings establish measurement invariance and provide support for further use of the TABS in the Caribbean. We discuss implications for medical curriculum development, including use of the TABS as a tool for medical students to reflect on their individual attitudes and beliefs regarding transgender people.
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Affiliation(s)
- Michael H Campbell
- Faculty of Medical Sciences, The University of the West Indies-Cave Hill, Bridgetown, BB11000, Barbados.
| | - Jill Gromer
- College of Social Work, Florida State University, Tallahassee, FL, USA
| | - Maisha K Emmanuel
- Faculty of Medical Sciences, The University of the West Indies-Cave Hill, Bridgetown, BB11000, Barbados
| | - Arianne Harvey
- Faculty of Medical Sciences, The University of the West Indies-Cave Hill, Bridgetown, BB11000, Barbados
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8
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Budhwani H, De P, Sun R. Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension. Popul Health Manag 2022; 25:164-171. [PMID: 35442794 PMCID: PMC9058871 DOI: 10.1089/pop.2021.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Stigma is one of the most harmful forces affecting population health. When stigma exists in clinical settings, environments that should be pro-patient and stigma-free, stigma may become internalized and affect patients' well-being. Informed by prior stigma research and the Intergroup Contact Theory, the authors elucidate statistical relationships between patients' perceptions of clinic-based stigma and stigma's impact on health among New York City's diverse residents. The authors hypothesize that perceiving stigma in clinical settings would mediate the relationships between depression, general health, diabetes, and hypertension; they tested this through multiple logistic regressions conducted on pooled data from the New York City Community Health Survey (N = 18,596, 2016-2017). Among women, depression was associated with stigma (α = 4.07, P < 0.01), hypertension (γ = 2.31, P < 0.01), diabetes (γ = 2.18, P < 0.01), and poor general health (γ = 6.34, P < 0.01). Among men, depression was associated with stigma (α = 3.7, P < 0.01), hypertension (γ = 2.35, P < 0.01), diabetes (γ = 1.86, P < 0.01), and poor general health (γ = 5.14, P < 0.01). Overall, perceived stigma in clinics significantly increased adjusted odds of self-reporting poor general health (adjusted ORs [AOR] = 1.87 men; AOR = 2.05 women). Findings contribute to the literature on the Intergroup Contact Theory, which suggests that stigma should be low in diverse communities; findings indicate that stigma may be a mediator, justifying inclusion in epidemiological and health services research. In addition, study outcomes suggest that depression may be associated with clinic-based stigma, and this stigma has deleterious effects on physical health. Thus, clinicians should emphasize stigma reduction in their facilities, potentially through the adoption of trauma-informed approaches or delivery of care using non-stigmatizing communication strategies, such as Motivational Interviewing.
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Affiliation(s)
- Henna Budhwani
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Prabal De
- City College and The Graduate Center, City University of New York, New York, New York, USA
| | - Ruoyan Sun
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
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9
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Budhwani H, Hearld KR, Butame SA, Naar S, Tapia L, Paulino-Ramírez R. Transgender Women in Dominican Republic: HIV, Stigma, Substances, and Sex Work. AIDS Patient Care STDS 2021; 35:488-494. [PMID: 34762515 PMCID: PMC8817706 DOI: 10.1089/apc.2021.0127] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Henna Budhwani
- University of Alabama at Birmingham (UAB), School of Public Health, Department of Health Care Organization and Policy, Birmingham, Alabama, USA
| | - Kristine R Hearld
- University of Alabama at Birmingham (UAB), School of Public Health, Department of Health Care Organization and Policy, Birmingham, Alabama, USA
| | - Seyram A Butame
- Florida State University College of Medicine (FSU), Center for Translational Behavioral Science (CTBScience), Tallahassee, Florida, USA
| | - Sylvie Naar
- Florida State University College of Medicine (FSU), Center for Translational Behavioral Science (CTBScience), Tallahassee, Florida, USA
| | - Leandro Tapia
- Instituto de Medicina Tropical & Salud Global, Universidad Iberoamericana (UNIBE), Santo Domingo, Dominican Republic
| | - Robert Paulino-Ramírez
- Instituto de Medicina Tropical & Salud Global, Universidad Iberoamericana (UNIBE), Santo Domingo, Dominican Republic
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10
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Budhwani H, Yigit I, Ofotokun I, Konkle-Parker DJ, Cohen MH, Wingood GM, Metsch LR, Adimora AA, Taylor TN, Wilson TE, Weiser SD, Kempf MC, Sosanya O, Gange S, Kassaye S, Turan B, Turan JM. Examining the Relationships Between Experienced and Anticipated Stigma in Health Care Settings, Patient-Provider Race Concordance, and Trust in Providers Among Women Living with HIV. AIDS Patient Care STDS 2021; 35:441-448. [PMID: 34739336 PMCID: PMC8817693 DOI: 10.1089/apc.2021.0096] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Stigma in health care settings can have negative consequences on women living with HIV, such as increasing the likelihood of missed visits and reducing trust in their clinical providers. Informed by prior stigma research and considering knowledge gaps related to the effect of patient-provider race concordance, we conducted this study to assess if patient-provider race concordance moderates the expected association between HIV-related stigma in health care settings and patients' trust in their providers. Moderation analyses were conducted using Women's Interagency HIV Study data (N = 931). We found significant main effects for patient-provider race concordance. Higher experienced stigma was associated with lower trust in providers in all patient-provider race combinations [White-White: B = -0.89, standard error (SE) = 0.14, p = 0.000, 95% confidence interval, CI (-1.161 to -0.624); Black patient-White provider: B = -0.19, SE = 0.06, p = 0.003, 95% CI (-0.309 to -0.062); and Black-Black: B = -0.30, SE = 0.14, p = 0.037, 95% CI (-0.575 to -0.017)]. Higher anticipated stigma was also associated with lower trust in providers [White-White: B = -0.42, SE = 0.07, p = 0.000, 95% CI (-0.552 to -0.289); Black patient-White provider: B = -0.17, SE = 0.03, p = 0.000, 95% CI (-0.232 to -0.106); and Black-Black: B = -0.18, SE = 0.06, p = 0.002, 95% CI (-0.293 to -0.066)]. Significant interaction effects indicated that the negative associations between experienced and anticipated HIV-related stigma and trust in providers were stronger for the White-White combination compared with the others. Thus, we found that significant relationships between HIV-related experienced and anticipated stigma in health care settings and trust in providers exist and that these associations vary across different patient-provider race combinations. Given that reduced trust in providers is associated with antiretroviral medication nonadherence and higher rates of missed clinical visits, interventions to address HIV-related stigma in health care settings may improve continuum of care outcomes.
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Affiliation(s)
- Henna Budhwani
- University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | | | - Igho Ofotokun
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | | | | | - Adaora A Adimora
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tonya N Taylor
- Downstate Health Sciences University, Brooklyn, New York, USA
| | - Tracey E Wilson
- Downstate Health Sciences University, Brooklyn, New York, USA
| | - Sheri D Weiser
- University of California, San Francisco, San Francisco, California, USA
| | | | | | | | - Seble Kassaye
- Georgetown University, Washington, District of Columbia, USA
| | | | - Janet M Turan
- University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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11
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Rafael RDMR, Jalil EM, Luz PM, de Castro CRV, Wilson EC, Monteiro L, Ramos M, Moreira RI, Veloso VG, Grinsztejn BGJ, Velasque LDS. Prevalence and factors associated with suicidal behavior among trans women in Rio de Janeiro, Brazil. PLoS One 2021; 16:e0259074. [PMID: 34679106 PMCID: PMC8535442 DOI: 10.1371/journal.pone.0259074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Trans women face disproportionate burden of adverse health outcomes, including mental health issues. Very little is known about suicidal behavior among trans women in low- and middle-income settings, such as Brazil. We aimed to estimate the prevalence of lifetime suicidal behavior and to identify its associated factors among Brazilian trans women. METHODS This was a cross-sectional study conducted among 345 trans women living in Rio de Janeiro, Brazil. We examined the prevalence of suicidal behavior (ideation and suicide attempt) and its associated factors using stepwise backward Poisson regression analysis with robust variance. RESULTS Suicidal ideation was present among 47.25% of participants, and the prevalence of lifetime suicide attempt was 27.25%. Trans women with prior physical violence perpetrated by a family member had significantly higher prevalence of suicidal ideation (adjusted prevalence ratios [aPR]1.37), whereas those who reported sex work had lower prevalence ratio of suicidal ideation (aPR 0.76). Suicide attempt was significantly associated with living alone (aPR 1.48), physical violence by a casual partner (aPR 1.92), and sexual violence by a family member (aPR 1.69). Depression was significantly associated with both outcomes (aPR 1.90 for suicidal ideation and aPR 2.21 for suicide attempt). CONCLUSION Suicidal behavior prevalence rates among Brazilian trans women were alarming and directly linked to violence and poor mental health. Effective mental health and public health policies addressing violence against trans women are urgently needed to prevent suicidal behavior among this highly vulnerable population.
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Affiliation(s)
| | - Emilia Moreira Jalil
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Paula Mendes Luz
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Erin C. Wilson
- San Francisco Department of Public Health, Center for Public Health Research, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Laylla Monteiro
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Michelle Ramos
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Ronaldo Ismério Moreira
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Valdiléa Gonçalves Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Luciane de Souza Velasque
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Department of Quantitative Methods, Federal University of Rio de Janeiro State, Rio de Janeiro, Brazil
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Dayton R, Alvarez B, Morales GJ, Rojas Almonte J, Faccini M, Gomes B, Wolf RC, Wilcher R. Assessing an inclusive model to increase access to comprehensive gender-based violence response services and improve HIV outcomes in Puerto Plata, Dominican Republic. CULTURE, HEALTH & SEXUALITY 2020; 22:1001-1017. [PMID: 31429671 DOI: 10.1080/13691058.2019.1647556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/18/2019] [Indexed: 06/10/2023]
Abstract
Experiences of gender-based violence (GBV) are associated with increased vulnerability to HIV and difficulty accessing HIV services; at the same time, people living with HIV are at an increased risk of GBV. Key populations most affected by HIV - gay and other men who have sex with men, female sex workers and transgender women - also experience a disproportionate burden of GBV. In Puerto Plata, Dominican Republic, a local civil society organisation has led efforts to improve and integrate GBV and HIV services while making them welcoming to key population members and people living with HIV. According to interviews with service providers and service users and an analysis of service statistics, the intervention improved service quality and coordination, increased disclosures of violence and increased GBV response service uptake among the general population, key population members and people living with HIV. Findings also suggest that the intervention increased the uptake of HIV services, including HIV testing and post-exposure prophylaxis, and improved mental health among those receiving GBV response services. This case study of integrated GBV and HIV services describes a new model for simultaneously, synergistically and inclusively addressing two major epidemics negatively affecting health and well-being in affected communities today.
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Affiliation(s)
- Robyn Dayton
- FHI 360, Global Health, Population and Nutrition, Durham, NC, USA
| | - Betty Alvarez
- Center for Promotion and Human Solidarity (CEPROSH), Puerto Plata, Dominican Republic
| | | | | | - Monica Faccini
- Center for Promotion and Human Solidarity (CEPROSH), Puerto Plata, Dominican Republic
| | - Bayardo Gomes
- Center for Promotion and Human Solidarity (CEPROSH), Puerto Plata, Dominican Republic
| | - R Cameron Wolf
- United States Agency for International Development (USAID), Office of HIV/AIDS, Global Health Bureau, Washington, DC, USA
| | - Rose Wilcher
- FHI 360, Global Health, Population and Nutrition, Durham, NC, USA
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Hearld KR, Budhwani H, Martínez-Órdenes M, Altaf A, Hasbun J, Waters J. Female Sex Workers' Experiences of Violence and Substance Use on the Haitian, Dominican Republic Border. Ann Glob Health 2020; 86:105. [PMID: 32874936 PMCID: PMC7442172 DOI: 10.5334/aogh.2889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - John Waters
- Caribbean Vulnerable Communities Coalition, JM
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Characterizing the role of intersecting stigmas and sustained inequities in driving HIV syndemics across low-to-middle-income settings. Curr Opin HIV AIDS 2020; 15:243-249. [PMID: 32487815 DOI: 10.1097/coh.0000000000000630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In 2020, key populations around the world still have disproportionate risks for HIV acquisition and experiencing HIV-related syndemics. This review presents current data around HIV-related syndemics among key populations globally, and on the role of intersecting stigmas in producing these syndemics in low-to-middle-income settings. RECENT FINDINGS Sex workers, sexual and gender minorities, prisoners, and people who use drugs experience high burdens of tuberculosis, sexually transmitted infections, viral hepatitis, and violence linked to heightened HIV-related risks or acquisition. Adverse sexual, reproductive, and mental health outcomes are also common and similarly amplify HIV acquisition and transmission risks, highlighting the need for psychosocial and reproductive health services for key populations. SUMMARY Achieving the promise of biomedical interventions to support HIV care and prevention requires action towards addressing syndemics of HIV, and the stigmas that reproduce them, among those most marginalized globally.
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Budhwani H, Sun R. Creating COVID-19 Stigma by Referencing the Novel Coronavirus as the "Chinese virus" on Twitter: Quantitative Analysis of Social Media Data. J Med Internet Res 2020; 22:e19301. [PMID: 32343669 PMCID: PMC7205030 DOI: 10.2196/19301] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 12/31/2022] Open
Abstract
Background Stigma is the deleterious, structural force that devalues members of groups that hold undesirable characteristics. Since stigma is created and reinforced by society—through in-person and online social interactions—referencing the novel coronavirus as the “Chinese virus” or “China virus” has the potential to create and perpetuate stigma. Objective The aim of this study was to assess if there was an increase in the prevalence and frequency of the phrases “Chinese virus” and “China virus” on Twitter after the March 16, 2020, US presidential reference of this term. Methods Using the Sysomos software (Sysomos, Inc), we extracted tweets from the United States using a list of keywords that were derivatives of “Chinese virus.” We compared tweets at the national and state levels posted between March 9 and March 15 (preperiod) with those posted between March 19 and March 25 (postperiod). We used Stata 16 (StataCorp) for quantitative analysis, and Python (Python Software Foundation) to plot a state-level heat map. Results A total of 16,535 “Chinese virus” or “China virus” tweets were identified in the preperiod, and 177,327 tweets were identified in the postperiod, illustrating a nearly ten-fold increase at the national level. All 50 states witnessed an increase in the number of tweets exclusively mentioning “Chinese virus” or “China virus” instead of coronavirus disease (COVID-19) or coronavirus. On average, 0.38 tweets referencing “Chinese virus” or “China virus” were posted per 10,000 people at the state level in the preperiod, and 4.08 of these stigmatizing tweets were posted in the postperiod, also indicating a ten-fold increase. The 5 states with the highest number of postperiod “Chinese virus” tweets were Pennsylvania (n=5249), New York (n=11,754), Florida (n=13,070), Texas (n=14,861), and California (n=19,442). Adjusting for population size, the 5 states with the highest prevalence of postperiod “Chinese virus” tweets were Arizona (5.85), New York (6.04), Florida (6.09), Nevada (7.72), and Wyoming (8.76). The 5 states with the largest increase in pre- to postperiod “Chinese virus” tweets were Kansas (n=697/58, 1202%), South Dakota (n=185/15, 1233%), Mississippi (n=749/54, 1387%), New Hampshire (n=582/41, 1420%), and Idaho (n=670/46, 1457%). Conclusions The rise in tweets referencing “Chinese virus” or “China virus,” along with the content of these tweets, indicate that knowledge translation may be occurring online and COVID-19 stigma is likely being perpetuated on Twitter.
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Affiliation(s)
- Henna Budhwani
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ruoyan Sun
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
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Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color? Med Care 2020; 57:960-967. [PMID: 31730568 DOI: 10.1097/mlr.0000000000001205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes. METHODS We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status. RESULTS Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08). CONCLUSIONS We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.
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Milner AN, Hearld KR, Abreau N, Budhwani H, Mayra Rodriguez-Lauzurique R, Paulino-Ramirez R. Sex work, social support, and stigma: Experiences of transgender women in the Dominican Republic. INT J TRANSGENDERISM 2019; 20:403-412. [PMID: 32999625 DOI: 10.1080/15532739.2019.1596862] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Transgender populations, and especially those in resource-limited settings, are at an elevated risk of experiencing stigma and discrimination. Aims: This study sought to examine the relationship between parental, familial, and other social support, experiences of stigma and discrimination, quality of life, and sex work in a national sample of transgender women in the Dominican Republic (n = 291). Methods: Descriptive analyses for the outcome variable, sex work, as well as for measures associated with socio-demographics, social support, stigma, quality of life, and experiences of abuse and violence were performed. Bivariate analysis examined differences between respondents involved in sex work and those not involved in sex work. Results: We found that participation in sex work was associated with low social support and quality of life and increased experiences of stigma, discrimination, and abuse. Specifically, Dominican transgender women involved in sex work received less social support than their non-sex working peers; they experienced heightened arguments and problems with non-parental family members, professors or bosses, classmates, and close friends, as well of loss of friendships. Involvement in sex work was also associated with higher levels of stigma and discrimination, lower quality of life, and experiences of sexual abuse, torture, and experiences of attempted murder on one's life. Discussion: Transgender women participating in sex work require more rather than less social support from family members and loved ones, especially in areas where workplace discrimination policies that affect transgender individuals are nebulous, such as the Dominican Republic.
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Affiliation(s)
| | | | - Nicole Abreau
- Universidad Iberoamericana-UNIBE, Santo Domingo, Dominican Republic
| | - Henna Budhwani
- University of Alabama at Birmingham, Birmingham, AL, USA
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Budhwani H, De P. Perceived Stigma in Health Care Settings and the Physical and Mental Health of People of Color in the United States. Health Equity 2019; 3:73-80. [PMID: 30915422 PMCID: PMC6434589 DOI: 10.1089/heq.2018.0079] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Addressing perceived and enacted stigma in clinical settings is critical to ensuring delivery of high-quality patient-centered care, reducing health disparities, and improving population health outcomes. Methods: Data from the Behavioral Risk Factor Surveillance System's (2012–2014) Reaction to Race module were analyzed to test the hypothesis that perceived stigma in health care settings would be associated with poorer physical and mental health. Poor health was measured by (1) the number of days the respondent was physically or mentally ill over the past month and (2) depressive disorder diagnosis. Multivariate linear and logistic regression models were employed. Results: Effects of stigma on physical and mental health were significant. Perceived stigma was associated with additional 2.79 poor physical health days (β=2.79, confidence interval [CI]=1.84–3.75) and 2.92 more days of poor mental health (β=2.92, CI=1.97–3.86). Moreover, perceived stigma in health care settings was associated with 61% higher odds of reporting a depressive disorder (adjusted odds ratio=1.61, CI=1.29–2.00). Among other findings, individuals who were married, younger, had higher income, had college degrees, and were employed reported significantly fewer poor physical and mental health days and had lower odds of self-reported depressive disorder. Conclusions: Reducing stigma against people of color in health care settings (environments that should be pro-patient) must be a top priority for population health scholars and clinicians. Reducing perceived stigma in clinical settings may produce better mental and physical health outcomes in minority patients thereby reducing health disparities. In addition, fewer days lost to poor health could positively influence the health care system by decreasing utilization and may improve economic productivity through increasing days of good health.
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Affiliation(s)
- Henna Budhwani
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Prabal De
- Department of Economics, Colin Powell School, City College, New York, New York.,Department of Economics, The Graduate Center, CUNY, New York, New York
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Hearld KR, Milner AN, Budhwani H, Abreau N, Rodriguez-Lauzurique RM, Charow R, Paulino-Ramirez R. Alcohol Use, High Risk Behaviors, and Experiences of Discrimination Among Transgender Women in the Dominican Republic. Subst Use Misuse 2019; 54:1725-1733. [PMID: 31046549 DOI: 10.1080/10826084.2019.1608253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: This study examines associations between alcohol use, high risk sexual behaviors, and experiences of stigma among transgender women across the Dominican Republic. Data from the 2015 Transgender Health Needs Study were analyzed using bivariate analyses (N = 291). Results: High rates of stigma, verbal abuse, alcohol use, and sex work are found and are associated with each other. Almost 45% of regular alcohol users are engaging in sex work (43.6%), compared with 31.1% of the non-regular alcohol users (χ2=4.82, p < .05). Having sex under the influence of alcohol is statistically associated with high risk behaviors, such as engaging in sex work, sometimes or never using a condom when receiving anal sex, and higher numbers of sexual partners. Furthermore, transgender women who have had sex under the influence of alcohol report statistically significantly higher levels of verbal abuse, discrimination, and levels of perceived transgender stigma. Conclusions/Importance: Findings suggest that although anti-discrimination laws exist, policies may not protect transgender women from experiencing stigma and discrimination at work, potentially forcing them to seek alternative careers and engage in behaviors that expose them to greater personal risk and harm. This intersection of factors may indicate a notable public health gap in transgender health in the Dominican Republic.
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Affiliation(s)
| | | | - Henna Budhwani
- a University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Nicole Abreau
- c Instituto de Medicina Tropical and Salud Global , Universidad Iberoamericana-UNIBE , Los Rios , Santo Domingo , República Dominicana
| | - Rosa Mayra Rodriguez-Lauzurique
- c Instituto de Medicina Tropical and Salud Global , Universidad Iberoamericana-UNIBE , Los Rios , Santo Domingo , República Dominicana.,d Centro de Orientacion e Investigacion Integral (COIN) , Santo Domingo , República Dominicana
| | - Rebecca Charow
- c Instituto de Medicina Tropical and Salud Global , Universidad Iberoamericana-UNIBE , Los Rios , Santo Domingo , República Dominicana
| | - Robert Paulino-Ramirez
- c Instituto de Medicina Tropical and Salud Global , Universidad Iberoamericana-UNIBE , Los Rios , Santo Domingo , República Dominicana.,d Centro de Orientacion e Investigacion Integral (COIN) , Santo Domingo , República Dominicana
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Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, Tillotson L, McGlaughlin E, Waters J. Transgender female sex workers' HIV knowledge, experienced stigma, and condom use in the Dominican Republic. PLoS One 2017; 12:e0186457. [PMID: 29095843 PMCID: PMC5667872 DOI: 10.1371/journal.pone.0186457] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 10/02/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Not only do transgender female sex workers have some of the highest rates of sexually transmitted infections (STI), human immunodeficiency virus (HIV), and experienced stigma, they also have higher likelihood of early sexual debut and some of the lowest levels of educational attainment compared to other stigmatized populations. Some of the most common interventions designed to reduce transmission of HIV and STIs seek to educate high-risk groups on sexual health and encourage condom use across all partner types; however, reaching stigmatized populations, particularly those in resource-limited settings, is particularly challenging. Considering the importance of condom use in stopping the spread of HIV, the aim of this study was two-fold; first to characterize this hard-to-reach population of transgender female sex workers in the Dominican Republic, and second, to assess associations between their HIV knowledge, experienced stigma, and condom use across three partner types. METHODS We analyzed self-reported data from the Questionnaire for Transgender Sex Workers (N = 78). Respondents were interviewed at their workplaces. Univariate and bivariate analyses were employed. Fisher Chi-square tests assessed differences in HIV knowledge and experienced stigma by condom use across partner types. RESULTS HIV knowledge was alarmingly low, condom use varied across partner type, and the respondents in our sample had high levels of experienced stigma. Average age of first sexual experience was 13.12 years with a youngest age reported of 7. Dominican Republic statutory rape laws indicate 18 years is the age of consent; thus, many of these transgender women's first sexual encounters would be considered forcible (rape) and constitute a prosecutable crime. On average, respondents reported 8.45 sexual partners in the prior month, with a maximum of 49 partners. Approximately two thirds of respondents used a condom the last time they had sex with a regular partner. This was considerably lower than condom use reported with coercive partners (92.96%) and clients (91.78%). Bivariate analyses revealed two trends: experienced stigma was associated with lower rates of condom use, and lower HIV knowledge was associated with lower rates of condom use. The former provides additional evidence that experienced stigma may become internalized, affecting individual-level behaviors-lowering self-confidence and resilience-making it more difficult to negotiate condom use due to lack of self-efficacy and desire to show trust in one's partner. The latter supports public health research that suggests gaps in HIV knowledge persist and are pronounced in highly stigmatized populations. DISCUSSION The vulnerabilities experienced by transgender persons, particularly in environments that vehemently adhere to conservative ideologies related to sex and gender, are significant and harm this population. These vulnerabilities could potentially be addressed through critically examining of impact of policies that indirectly promote or allow victimization of transgender citizens and subsequently diminish the effectiveness of public health and educational interventions. By taking action through the revocation of such laws, the Dominican Republic has the opportunity to improve overall population health, to protect some of its most stigmatized citizens, and to become the flag bearer of enhanced human rights in the Caribbean and Latin America.
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Affiliation(s)
- Henna Budhwani
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Kristine R. Hearld
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Julia Hasbun
- Centro de Orientación e Investigación Integral (COIN), Calle Arzobispo Meriño, Santo Domingo, Dominican Republic
| | - Rebecca Charow
- Caribbean Vulnerable Communities Coalition (CVC), Kingston, Jamaica
| | - Santo Rosario
- Centro de Orientación e Investigación Integral (COIN), Calle Arzobispo Meriño, Santo Domingo, Dominican Republic
| | - Louise Tillotson
- Centro de Orientación e Investigación Integral (COIN), Calle Arzobispo Meriño, Santo Domingo, Dominican Republic
| | | | - John Waters
- Caribbean Vulnerable Communities Coalition (CVC), Kingston, Jamaica
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