Prevalence and factors associated with suicidal behavior among trans women in Rio de Janeiro, Brazil

Childhood Parental Neglect, Abuse and Rejection Among Transgender Women: A Cross-Sectional Study in Rio de Janeiro, Brazil

We aimed to estimate the proportions of childhood parental neglect, abuse, and rejection and to evaluate the co-occurrence of these experiences among transgender women in Rio de Janeiro, Brazil. This was a cross-sectional study with a convenience sample enrolled between July 2019 and March 2020, using an adapted version of the Childhood Trauma Questionnaire. Proportions and corresponding confidence intervals (CI) were calculated. Kendall correlation with Tau-b estimator was used in the bivariate analyses. We gathered data from 139 participants. The most prevalent types of childhood traumas were emotional abuse (60.43%, 95% CI [51.79, 68.62]), physical abuse (57.55%, 95% CI [48.90, 65.89]) and sexual abuse (44.60%, 95% CI [36.18, 53.27]). Severe to extreme physical and emotional abuse occurred among 40.29% (95% CI [32.06, 48.93]) and 5.75% (95% CI [2.51, 11.02]) of participants, respectively. The proportion of parental rejection (eviction) was 32.37% (95% CI [25.04, 40.69]) and occurred with the other forms of abuse, except sexual abuse. Multiple types of childhood abuse, neglect, and parental rejection were observed among transgender women in our sample. The harmful effects of childhood abuse on the mental and physical health of people in the transgender population are of concern, particularly considering the cumulative effect produced by the co-occurrence of such events and their harmful lifetime effects. It is urgently necessary to debate and formulate public policies to ensure the right to gender expression from childhood.

Mental health of LGBTQ+ workers: a systematic review

BACKGROUND

Members of the lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) community have greater risk of mental health disorders compared to the general population, however most evidence is from young people. We sought to systematically review and summarise the evidence for the burden and risk of mental health disorders.

METHODS

A PRISMA-compliant literature search was conducted in MEDLINE, Embase, PsycInfo, Scopus, and CINAHL for articles published from 2000 to 2024. Quantitative or mixed-methods studies that reported mental health outcomes among LGBTQ+ workers were included. Effect measures included prevalence and odds ratios, with variations in mental health across occupations and specific sexual or gender minorities reported where possible. This systematic review was prospectively registered through PROSPERO (CRD42024587605).

RESULTS

Out of 5736 unique articles screened, 33 articles (32 individual studies) fulfilled eligibility criteria, including 8369 LGBTQ+ workers. Other than studies of sex workers, only 12 studies had research questions specific to LGBTQ+ workers' mental health. Most studies (30/32) were cross-sectional and reported increased odds of depression, anxiety, or suicidality among LGBTQ+ compared to non-LGBTQ+ workers. Prevalence estimates and methodology varied widely. Factors associated with adverse mental health outcomes among select groups of LGBTQ+ workers included internalised stigma, heterosexism, job stress and low income. We found no studies comparing workers across industries and no studies involving workplace interventions.

CONCLUSIONS

There are limited objective data regarding LGBTQ+ workers' mental health. Given the heterogeneity of the LGBTQ+ population, dedicated longitudinal research into the mental health of specific sexual and gender minorities across all industries and occupations is needed to determine causal factors, the impact of intersectionality, and the effectiveness of workplace interventions.

Intimate Partner Violence Among Brazilian Trans and Cisgender Women Living with HIV or at HIV Risk During COVID-19 Era: Another Epidemic?

Purpose

Our study was conducted to estimate intimate partner violence (IPV) prevalence and associated factors among trans and cisgender women at risk of or living with HIV during the coronavirus disease (COVID-19) pandemic in Rio de Janeiro, Brazil.

Methods

A cross-sectional study was conducted between May and August 2020 through telephone surveys with cisgender and trans women enrolled in two cohort studies in Rio de Janeiro. We assessed IPV employing the Revised Conflict Tactics Scale during the initial months of shelter-in-place ordinances. Regression models evaluated the factors associated with IPV for each population.

Results

We surveyed 796 women, and 341 participants (47.78%) were eligible and included in the current analysis. All cisgender women and 41 (64.06%) trans women were living with HIV. Overall IPV prevalence was 27.86% (95% confidence interval [95% CI] 23.34-32.88). IPV was 63% higher among trans women than among cisgender women (prevalence ratio 1.63, 95% CI 1.14-2.34, p=0.008). Loneliness was significantly associated with IPV in both groups. Younger age and binge drinking were associated with IPV prevalence among trans women. For cisgender women, IPV was associated with withdrawal of cash transfer programs during the shelter-in-place.

Conclusion

Trans women experienced significantly more IPV than cisgender women in the early phase of the COVID-19 epidemic. Plans to prevent and address violence against cisgender and trans women, especially those with heightened vulnerability that may be associated with living with HIV, are needed in public health planning for future pandemics.

Relationship between childhood abuse and self-harm among transvestites and transgender women in Rio de Janeiro state 2019-2020

OBJECTIVE

To analyze the relationship between childhood abuse and self-harm in a group of transvestites and transgender women from the state of Rio de Janeiro.

METHODS

This was a cross-sectional study conducted with 139 participants selected through convenience sampling between 2019 and 2020. A structured questionnaire was used for data collection. The odds ratio (OR) and 95% confidence intervals (95%CI) for suicidal ideation, suicide attempts, and self-harm were calculated using logistic regression.

RESULTS

Having experienced emotional abuse in childhood increased the suicide attempt (OR=9.00; 95%CI 1.13;71.34), having experienced psychological violence in childhood increased self-injurious behavior (OR=11.64; 95%CI 2.35;57.5), HIV infection increased suicidal ideation (OR=2.38; 95%CI 1.09;5.21).

CONCLUSION

Childhood abuse, as well as the experience of stigmatizing diseases, increased the risk of self-harm among this population.

Social and programmatic vulnerability in the context of transgender people's health: a scoping review of scientific evidence from Brazil

BACKGROUND

Most transgender people face different conditions of health vulnerability on a daily basis. In the Brazilian context, no research review has been found on such situations in the light of the theoretical conceptualization of multidimensional vulnerability. This research aimed to identify and analyze components of social and/or programmatic vulnerability that interfere with access to health care for trans people in Brazil.

METHODS

The scoping review followed the JBI Manual and the PRISMA-ScR list. Brazilian studies published in any language, in the period 2019-April 2023, in the NCBI/PubMed, Web of Science, EMBASE, Scopus, SciELO, and LILACS databases were selected. The inclusion criteria included: original research with a sample of transgender people aged 18 years and over; and research contemplating conditions of social and/or programmatic vulnerability. Three reviewers independently selected the articles. The extracted and mapped data included components of these dimensions, according to the theoretical framework, as well as characteristics of the studies, for the synthesis of the descriptive analysis.

RESULTS

A total of 46 studies were included. Social and programmatic vulnerability components were present in 67% of the studies. Among the main findings, the social dimension included discrimination, situations of violence in different contexts and social exclusion; prejudice and school dropout, homelessness, informal work and precarious income; and harmful use of alcohol and/or other drugs. The programmatic dimension encompassed disrespect for the use of the social name and institutional discrimination; hormone therapy without professional monitoring and scarcity of specialized services; lack of integration between Primary Health Care (PHC) and specialized care and insufficient PHC involvement; distortions between what is contained in public health policies and the practice in the services. A higher percentage (61%) of studies with trans women and 7% with trans men were observed; inequalities in regional distribution; predominance of HIV and AIDS and mental health themes; and similar percentages in the various methodological approaches and publications in national and foreign journals.

CONCLUSION

The identified situations of vulnerability contribute mainly to supporting the formulation and implementation of new public policies in comprehensive health that are more comprehensive and inclusive, which mitigate the current social and health inequities.

Factors Associated with Transgender-Based Discrimination Among Travestis and Transgender Women in Rio de Janeiro, Brazil

Purpose

Transgender-based discrimination is associated with poor mental health, unemployment, and poverty. Travestis and transgender women (trans women) frequently experience transgender-based discrimination, but associated factors are understudied. Our objective was to identify the factors associated with transgender-based discrimination among trans women from Brazil.

Methods

We used data from Transcendendo, a clinic-based cohort of trans women in Rio de Janeiro, Brazil. Eligible participants were ≥18 years old, assigned male sex at birth, and self-identified as travestis, transgender women, or other trans feminine identities. We analyzed baseline data for participants enrolled from August 2015 to March 2020. Face-to-face questionnaires collected data on socio-demographics, gender identity and expression, and transgender-based discrimination experience. Factors associated with transgender-based discrimination were evaluated through multivariable linear regression.

Results

Out of the 587 participants, 559 (95%) were included (28 excluded due to missing data). Mean age was 33 years, the majority identified as transgender women (40%), 71% reported current or past sex work, and 43% self-reported as living with HIV. In multivariable regression models, factors significantly associated with transgender-based discrimination included having no supporting or one supporting parental figure (vs. support from both parents), living in poverty (vs. not), and current and past sex work (vs. never).

Conclusions

Trans women without family support, who engaged in sex work or were economically deprived were more prone to transgender-based discrimination. A lack of parental support, the strongest independent predictor of transgender-based discrimination experiences, likely contributes to emotional and structural vulnerabilities.

Accuracy, potential, and limitations of probabilistic record linkage in identifying deaths by gender identity and sexual orientation in the state of Rio De Janeiro, Brazil

BACKGROUND

Globally, the counting of deaths based on gender identity and sexual orientation has been a challenge for health systems. In most cases, non-governmental organizations have dedicated themselves to this work. Despite these efforts in generating information, the scarcity of official data presents significant limitations in policy formulation and actions guided by population needs. Therefore, this manuscript aims to evaluate the accuracy, potential, and limits of probabilistic data relationships to yield information on deaths according to gender identity and sexual orientation in the State of Rio de Janeiro.

METHODS

This study evaluated the accuracy of the probabilistic record linkage to obtain information on deaths according to gender and sexual orientation. Data from two information systems were used from June 15, 2015 to December 31, 2020. We constructed nine probabilistic data relationship strategies and identified the performance and cutoff points of the best strategy.

RESULTS

The best data blocking strategy was established through logical blocks with the first and last names, birthdate, and mother's name in the pairing strategy. With a population base of 80,178 records, 1556 deaths were retrieved. With an area under the curve of 0.979, this strategy presented 93.26% accuracy, 98.46% sensitivity, and 90.04% specificity for the cutoff point ≥ 17.9 of the data relationship score. The adoption of the cutoff point optimized the manual review phase, identifying 2259 (90.04%) of the 2509 false pairs and identifying 1532 (98.46%) of the 1556 true pairs.

CONCLUSION

With the identification of possible strategies for determining probabilistic data relationships, the retrieval of information on mortality according to sexual and gender markers has become feasible. Based on information from the daily routine of health services, the formulation of public policies that consider the LGBTQ + population more closely reflects the reality experienced by these population groups.

Associations between early child adversity and lifetime suicide attempts among gender diverse individuals: A moderated mediation

BACKGROUND

This study examines the effect of adverse childhood experiences (ACEs) on lifetime suicide attempts (LSA) across five gender subgroups (i.e., transgender men, transgender women, transgender non-binary, cisgender men and cisgender women).

OBJECTIVE

To examine (1) the prevalence of LSA across gender identity subgroups; (2) whether the association between ACEs and LSA is moderated by gender identity subgroup; (3) depressive symptoms, alcohol use disorder, social support, and social well-being as mechanisms linking ACEs with LSA; and (4) the moderating role of gender identity on the four putative mediators.

PARTICIPANTS AND SETTINGS

We used nationally representative data from a population-based survey of N = 1368 transgender and cisgender individuals collected between 2016 and 2019.

METHODS

Structural equation modeling was used to explore the indirect effect of depressive symptoms on the relation between ACEs and LSA, and the moderating impact of gender identity.

RESULTS

LSA was significantly more prevalent among transgender respondents (cisgender man = 5 %; cisgender woman = 9 %; transgender man = 42 %; transgender woman = 33 %; transgender non-binary = 37 %; p < 0.001). Individuals with more ACEs had a greater risk of engaging in LSA regardless of gender identity; however, moderation results showed that the impact of each additional ACE on LSA was stronger for individuals with transgender identities: the likelihood of engaging in LSA was statistically similar for transgender men with no ACEs and cisgender men with all 8 ACEs. Indirect effects of ACEs on LSA via depressive symptoms were also observed, and the mediating effect was moderated by gender identity.

CONCLUSIONS

By examining the mechanisms linking childhood adversity to LSA, this study demonstrates that not all ACEs impact gender minority subgroups equally.

Theoretical-methodological essay on gender identity information validity in epidemiological surveillance of violence

The inclusion of the "gender identity" field in the Brazilian violence surveillance system, although representing a step forward, still has limitations that may compromise epidemiological data validity. Existing response options for victims' identities do not adequately cover the diversity of this analysis category, resulting in classification biases. Additionally, the absence of options for cisgender identities reflects an approach that naturalizes these identities, while trans identities are considered deviant and subject to surveillance. To overcome these limitations, it is imperative to adopt a broader understanding of gender as a social and performative construction. This requires a reassessment of social structures and data collection instruments. In this context of discussion, this theoretical-methodological essay aims to reflect on gender identity measurement in the Reporting Diseases System interpersonal and self-inflicted violence surveillance system, taking as frameworks the theoretical conceptions about gender as a performative act and the foundations of validity in epidemiological investigations.

Mental health in transgender individuals: a systematic review

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.

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

BACKGROUND

To 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.

METHODS

Interviewer-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.

RESULTS

Violence 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.

CONCLUSION

Our 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.