Sex and gender in the US health surveillance system: a call to action

Limitations of Sexual Orientation and Gender Identity Information as Reported in the National Violent Death Reporting System

The National Violent Death Reporting System (NVDRS) is a Centers for Disease Control and Prevention (CDC) restricted-access database detailing precipitating circumstances to U.S. violent deaths. In 2013 and 2015, the CDC added codes denoting sexual orientation and gender identity (SOGI) and sex of partner. In the past decade, researchers have leveraged NVDRS data to document SOGI-related patterns and characteristics of violent death including suicide. Yet, there are substantial limitations to NVDRS SOGI information that should be considered in responsible reporting by researchers and informed assessment by reviewers. In this perspective, we summarize some of these challenges and offer recommendations for using NVDRS SOGI data responsibly.

Examining Sexual and Dating Violence by Gender Identity Among High School Students

PURPOSE

This study examined the reporting of sexual and dating violence among high school students using a standard gender identity question.

METHODS

Using data from the 2017 and 2019 Youth Risk Behavior Surveys, multivariable regression models estimated the association between gender identity and four measures of sexual and dating violence, adjusted for confounding by race/ethnicity, grade, and reported sex.

RESULTS

Of the 198,900 teenagers, 1.8% identified as transgender, 1.6% were not sure, and 1.9% responded that they did not know what question was being asked. Across all measures of violence, transgender, "unsure" and "don't understand" students were significantly more likely than cisgender students to report having been victimized.

DISCUSSION

Standard analysis practices of eliminating unsure and/or don't understand responses to gender identity questions may underestimate at-risk youth. Researchers seeking to understand disparities in youth violence by gender identity will need to ensure that they employ inclusive measures.

Social Determinants of Health in Urban Transgender Patients: A Case Report

The social determinants of health (SDOH) are a complex web of factors that influence the health of individuals throughout their lifetime. There are many drivers of health inequities within the SDOH, such as socioeconomic status, education, employment, gender, and race/ethnicity. It is possible that mental illness may develop when these factors negatively affect health. However, current research primarily focuses on SDOH in cisgender individuals leaving a scientific gap in transgender individuals who require unique considerations when providing comprehensive medical care. We present the case of a 20-year-old transgender female who was admitted for suicidal attempts during a methamphetamine overdose, and who had been struggling with mental illness and suicidal gestures since she was a young teenager. The significance of our findings is discussed in the context of the substantial lack of current research on SDOH in transgender individuals to underscore the need for clinical awareness and promote future research.

A scoping review of survey research with gender minority adolescents and youth in low and middle-income countries

BACKGROUND

Survey data that categorizes gender identity in binary terms and conflates sex and gender limits knowledge around the experience of gender minority populations, whose gender identity or expression does not align with the sex they were assigned at birth. In this review, we outline the existing survey research on the experience of a gender minority demographic for whom there is particularly limited data: adolescents and youth in low and middle-income countries (LMICs).

METHODS

This paper is a scoping review of peer-reviewed articles, published in English, that use survey data to examine the experience of gender minority adolescents and youth in LMICs. We conducted a search on two major databases using key terms related to gender identity, adolescence and youth, and country and region. This search yielded 385 articles. Following a team-conducted review, we retained 33 articles for the final analysis.

RESULTS

Our review shows that surveys with adolescents and youth in LMICs are increasingly including questions and taking sampling approaches that allow gender minority populations to be visible in survey data. Surveys that do so are largely focused in upper middle-income countries (n = 24), rather than lower middle-income or low-income countries, with South East Asia a notable sub-region of focus (n = 15). Sexual health, mental health, and violence are key topics of interest. Most of the surveys rely on some form of network-driven sampling focused on sexual and/or gender minorities (n = 22). The studies vary in how they ask about gender identity, both in terms of question formulation and the answer categories that are offered, as well as the extent to which they describe the questions in the article text.

CONCLUSIONS

This review reveals a growing body of work that provides important insights into the experiences of gender minority adolescents and youth in LMICs. More studies could integrate these approaches, but it must be done in a way that is thoughtful about cultural and political context. Given the relatively nascent nature of such research, we encourage scholars to continue providing details on methodology, including around participant recruitment and the development of gender identity questions. This information would be valuable for researchers seeking to better include gender minorities and their experiences in survey research, but who might be daunted methodologically.

Sexual and Gender Minority Youth in Foster Care: An Evidence-Based Theoretical Conceptual Model of Disproportionality and Psychological Comorbidities

Sexual and gender minority youth (SGMY) are overrepresented in the foster care system and experience greater foster-care-related stressors than their non-SGM peers. These factors may further elevate their risk of anxiety/depressive, post-traumatic stress disorder, self-harm, and suicidality. The system currently produces unequal and disproportionate adverse mental health outcomes for SGMY and needs points of intervention to disrupt this status quo. This article provides an empirically grounded conceptual-theoretical model of disproportionate representation and burden of psychological comorbidities experienced by SGMY in the foster care system. We apply findings from an integrated literature review of empirical research on factors related to overrepresentation and mental health burden among SGMY to minority stress theory to explicate how and why the foster care system exacerbates mental health comorbidities for SGMY. Searches were conducted in June 2020 in PubMed using MeSH terms and title/abstract terms for foster care, sexual or gender minorities, and psychological comorbidities. Inclusion criteria are studies conducted in the United States, published in English, focused on mental illness, and published between June 2010 and 2020. Developmental/intellectual and eating disorders were excluded. The initial search returned 490 results. After applying inclusion criteria, 229 results remained and are utilized to build our conceptual-theoretical model. We assert that the phenomenon of disproportionate psychological comorbidities for SGMY in foster care is best represented as a complex and dynamic system with multiple feedback loops. Extant empirical and theoretical literature identifies three critical areas for intervention: family acceptance, community belonging and queer chosen/constructed family, and affirming and nondiscriminatory child welfare policy.

An Analysis of the Use of the Terms Sex and Gender in Research Reported in Nursing Journals

Accurately measuring and reporting the demographic characteristics of research participants are imperative to provide consumers of research with an understanding of who was included in a study. While researchers often, incorrectly, use the variables sex and gender interchangeably, these 2 variables are different. We conducted a content analysis of 239 randomly selected research articles, with the purpose of describing how researchers have used sex and gender in studies published in nursing journals and identifying opportunities for improved clarity and precision in measuring these 2 variables. We found that significant improvement is needed in the way these variables are used/reported.

Structural sexism and Women's alcohol use in the United States, 1988-2016

BACKGROUND

Women's alcohol consumption and binge drinking have increased concurrent with socio-economic gains and may be related to structural sexism.

METHODS

We examined associations between structural sexism (state-level sex inequality in political/economic status), and alcohol outcomes among women in Monitoring the Future (N = 20,859) from 1988 to 2016 (ages 27-45 in 2016). We controlled for state and individual confounders and tested three mediators: depressive symptoms, restrictive alcohol norms, and college completion.

RESULTS

Increased structural sexism was associated with decreased alcohol consumption frequency (RR: 0.974, 95% CI: 0.971, 0.976) and binge drinking probability (OR: 0.917, 95% CI: 0.909, 0.926). Norms and education but not depressive symptoms partially mediated these relationships.

CONCLUSION

Among women in the midlife in recent years, lower levels of state structural sexism were associated with greater alcohol consumption and binge drinking. These findings suggest that as states become more gender-equal-which confer numerous benefits for women's rights and health-additional resources and messaging may be required to prevent harmful alcohol use among women.

Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations

OBJECTIVE

Two-step questions to assess gender identity are recommended for optimizing care delivery for gender-diverse individuals. As gender identity fields are increasingly integrated into electronic health records, guidance is needed on how to analyze these data. The goal of this study was to assess potential approaches for analyzing 2-step gender identity questions and the impact of each on suicidal ideation.

MATERIALS AND METHODS

A regional Youth Risk Behavior Survey in one Northeastern school district used a 2-step question to assess gender identity. Three gender measurement strategies (GMSs) were used to operationalize gender identity, (1) combining all gender-diverse youth (GDY) into one category, (2) grouping GDY based on sex assigned at birth, and (3) categorizing GDY based on binary and nonbinary identities. Mixed-effects logistic regression was used to compare odds of suicidal ideation between gender identity categories for each GMS.

RESULTS

Of the 3010 participants, 8.3% were GDY. Subcategories of GDY had significantly higher odds (odds ratio range, 1.6-2.9) of suicidal ideation than cisgender girls regardless of GMS, while every category of GDY had significantly higher odds (odds ratio range, 2.1-5.0) of suicidal ideation than cisgender boys.

CONCLUSIONS

The field of clinical informatics has an opportunity to incorporate inclusive items like the 2-step gender identity question into electronic health records to optimize care and strengthen clinical research. Analysis of the 2-step gender identity question impacts study results and interpretation. Attention to how data about GDY are captured will support for more nuanced, tailored analyses that better reflect unique experiences within this population.

The Treatment of LGBTQ+ Individuals in Behavior-Analytic Publications: A Historical Review

The purpose of this article is to review behavior-analytic publications to understand the field's history of including lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+) individuals in research publications. Twelve articles met the inclusionary criteria for review. The results of the review suggested that the representation of LGBTQ+ individuals is lacking in behavior-analytic literature. Of the 12 articles identified, two were categorized as experimental, three as commentaries, three as survey research, two as conceptual, and two as calls to action. The most prominent period for related publications was between 1973 and 1977, with long periods between other articles that were published in 1990, 1996, 2018, and 2019. Experiments published in the 1970s were associated with conversion therapy, to attempt to change an individual's sexual or gender identity. However, other behavior analysts in the 1970s opposed these experiments. Since these early experiments, there have been no other interventions targeted at affecting the lives of gender and sexual minorities. Behavior analysts must address issues of significance faced by LGBTQ+ individuals through increasing affirming practices, reducing health disparities, increasing safety in schools, and more.

Global scoping review of HIV prevention research with transgender people: Transcending from trans-subsumed to trans-centred research

INTRODUCTION

Globally, transgender populations are disproportionally impacted by HIV and effective HIV prevention interventions targeting these populations are critically needed. Such interventions require research focused on the specific needs and experiences of transgender people. This methodological review aims to determine the extent to which HIV prevention research has included transgender participants by subsuming them into non-transgender populations, or by centring them either in comparison with other groups or as the sole focus of research.

METHODS

We searched five electronic databases (e.g. SCOPUS) for empirical studies that focused on HIV prevention and included transgender participants, published through 31 December 2020. For each study, we extracted information on: (a) types of inclusion of transgender participants; (b) total sample size and number/percentage of transgender participants; (c) country(ies) where study was conducted; (d) HIV research topics; (e) methods (i.e. quantitative, qualitative or mixed-methods research) and (f) gender identity of transgender participants.

RESULTS AND DISCUSSION

Of 667 HIV prevention studies included in the review, 38.5% subsumed transgender participants into cisgender populations (most frequently combining transgender women with cisgender men who have sex with men), 20.4% compared transgender and cisgender participants and 41.1% focused exclusively on transgender populations. Our global scoping review also revealed that these three types of transgender inclusion in HIV prevention research vary greatly over time, place and thematic areas. Transgender women are the focus of the majority of reviewed studies, whereas transgender men and gender expansive people are rarely included as participants.

CONCLUSIONS

Inclusion of transgender persons as participants in HIV prevention research has significantly increased, particularly in the last decade. Further research centred on transgender participants and their experiences are needed to develop effective HIV prevention interventions for transgender populations. We advocate for HIV prevention research to move from subsuming transgender people, to trans-centred research that asks questions that focus on their specific needs and experiences. We provide recommendations to move from trans-subsumed to trans-centred HIV prevention research.

Identification of Transgender People With Cancer in Electronic Health Records: Recommendations Based on CancerLinQ Observations

PURPOSE

Cancer prevalence and outcomes data, necessary to understand disparities in transgender populations, are significantly hampered because gender identity data are not routinely collected. A database of clinical data on people with cancer, CancerLinQ, is operated by the ASCO and collected from practices across the United States and multiple electronic health records.

METHODS

To attempt to identify transgender people with cancer within CancerLinQ, we used three criteria: (1) International Classification of Diseases 9/10 diagnosis (Dx) code suggestive of transgender identity; (2) male gender and Dx of cervical, endometrial, ovarian, fallopian tube, or other related cancer; and (3) female gender and Dx of prostate, testicular, penile, or other related cancer. Charts were abstracted to confirm transgender identity.

RESULTS

Five hundred fifty-seven cases matched inclusion criteria and two hundred and forty-two were abstracted. Seventy-six percent of patients with Dx codes suggestive of transgender identity were transgender. Only 2% and 3% of the people identified by criteria 2 and 3 had evidence of transgender identity, respectively. Extrapolating to nonabstracted data, we would expect to identify an additional four individuals in category 2 and an additional three individuals in category 3, or a total of 44. The total population in CancerLinQ is approximately 1,300,000. Thus, our methods could identify 0.003% of the total population as transgender.

CONCLUSION

Given the need for data regarding transgender people with cancer and the deficiencies of current data resources, a national concerted effort is needed to prospectively collect gender identity data. These efforts will require systemic efforts to create safe healthcare environments for transgender people.

Screening for Gender Identity in Adolescent Well Visits: Is It Feasible and Acceptable?

PURPOSE

This study aimed to pilot systematic gender identity screening during adolescent well checks and examine perceptions of feasibility and acceptability of screening from adolescents, parents/guardians, and clinicians.

METHODS

Adolescents aged 12-18 years with a well visit between July 1, 2018, and June 30, 2019 (n = 134,114; 817 pilot and 133,297 usual care) in Kaiser Permanente Northern California (KPNC) pediatric primary care clinics. "What is your gender?" was added to the previsit questionnaire in pilot clinics; all other KPNC clinics provided usual care. Additional anonymous surveys were administered to adolescents and parents/guardians in the pilot clinics and to all KPNC pediatric clinicians. Multivariable logistic regression examined associations between clinics and patients reporting as transgender and gender diverse (TGD). Descriptive statistics summarized patient, parent/guardian, and clinician perceptions of gender identity screening.

RESULTS

Adjusting for age and race/ethnicity, adolescents had higher odds of reporting as TGD in pilot clinics than in usual care (odds ratio = 6.91, 95% confidence interval = 3.76-12.74). Two thirds of adolescents, 75.5% of parents/guardians, and 92.5% of clinicians felt it was important to screen for gender identity in primary care. Less than 2% of adolescents found the question confusing, offensive, or uncomfortable, and 2.8% of parents/guardians felt it was offensive. In addition, 36.4% of clinicians and 3.6% of parents/guardians were concerned it would affect visit workflow/time.

CONCLUSIONS

Most adolescents, parents/guardians, and pediatric clinicians viewed systematic gender identity screening as both feasible and acceptable. Standardized gender identity screening during adolescent well checks could facilitate and increase identification of TGD adolescents and the delivery of gender-affirming care for adolescents and families in need.

Perspectives from Transgender and Gender Diverse People on How to Ask About Gender

Purpose: When inquiring about the gender of research participants, most studies use self-generated questions about gender or questions prepared by researchers that have been evaluated for comprehension by transgender and gender diverse (TGD) and cisgender individuals. However, many gaps still exist in this area, including identifying how TGD people would like to see their gender represented in questions about gender identity. To address this issue, we explored the perspectives of TGD people regarding the construction of questions about gender. Methods: In this online study of 695 TGD people (Mage = 25.52), participants provided written suggestions for how to ask about gender and these responses were analyzed thematically. Data were collected between fall 2015 and summer 2017. Results: Three broad categories of responses emerged: (1) specific identities to include in response options; (2) specific questions to ask about gender; and (3) qualifiers/nuanced considerations. Conclusion: Participants provided a variety of suggestions for how to ask about gender and future research is needed to explore the implementation of these suggestions. Recommendations are provided for options that researchers can explore for how to ask about gender. These findings highlight the ways that TGD people would like their gender to be asked about, which is necessary information to ensure that questions about gender reflect TGD people's identities accurately.

Adolescent Smoking Susceptibility: Gender-Stratified Racial and Ethnic Differences, 1999-2018

INTRODUCTION

Susceptibility, or openness to smoking, is a predictor of future smoking. This study examines within-gender racial/ethnic differences in smoking susceptibility over historical time (1999-2018) and developmental age (11-18 years).

METHODS

Data were obtained from 205,056 adolescent never smokers in 14 waves of the National Youth Tobacco Survey. Weighted time-varying effect models were used to estimate nonlinear trends in smoking susceptibility among minority (versus white) adolescents. Analyses were conducted in 2019.

RESULTS

Compared with whites, Latino/a adolescents were consistently more susceptible to smoking, whereas black and Asian adolescents fluctuated between being less and equally susceptible over time. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander adolescents were more susceptible from 2014 to 2017, with differences being larger for girls. Susceptibility peaked at age 14 years. Compared with whites, Latino/a adolescents were more susceptible throughout adolescence. Black adolescents were more susceptible in early adolescence, whereas Asian adolescents were less or equally susceptible to smoking in early to mid-adolescence. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were more susceptible in early and mid-adolescence, but boys were more susceptible in early adolescence only. American Indian, Alaska Native, Native Hawaiian, and Pacific Islander girls were less susceptible than white girls aged 18 years.

CONCLUSIONS

Twenty-year racial/ethnic differences in smoking susceptibility were evident, particularly among girls, but were mostly equivalent between genders over developmental age. Targeting susceptible adolescents with gender-, race/ethnic-, and age-tailored prevention efforts may prevent or delay adolescents' transition to tobacco use and reduce tobacco-related disparities.

Youth-Serving Professionals' Perspectives on HIV Prevention Tools and Strategies Appropriate for Adolescent Gay and Bisexual Males and Transgender Youth

INTRODUCTION

HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education.

METHODS

Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study.

RESULTS

Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools.

DISCUSSION

Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

The health status of transgender and gender nonbinary adults in the United States

The goal of this exploratory study was to delineate health differences among transgender subpopulations (transgender women/TW, transgender men/TM, gender nonbinary/GNB adults). 2015 Behavioral Risk Factor Surveillance System data were analyzed to compare the health of three groups (TW:N = 369; TM:N = 239; GNB:N = 156). Logistic regression and adjusted odds ratios were used to determine whether health outcomes (fair/poor health, frequent physical and mental unhealthy days, chronic health conditions, and health problems/impairments) are related to group and its interaction with personal characteristics and socioeconomic position. Group was a significant predictor of fair/poor health and frequent mental unhealthy days, revealing significant health differences between the transgender groups. The odds of poor/fair health were approximately 2.5 times higher in TM and GNB adults relative to TW. The odds of frequent mental unhealthy days for TM were approximately 1.5-2 times greater than TW and GNB adults. Among those with health insurance, the odds of fair/poor health for GNB adults was more than 1.5-2 times higher that of TM and TW. Among those without health insurance, TM had over 7 times greater odds of fair/poor health than TW. This study underscores the importance of classifying and examining the health of the transgender population as unique subpopulations, as notable health differences were discovered. TM and GNB adults have significant health concerns, requiring the attention of clinical interventions aimed at promoting health and preventing illness.

Words Matter: Sex and Gender as Unique Variables in Research

Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar. Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided.

Family, School, and Peer Support Are Associated With Rates of Violence Victimization and Self-Harm Among Gender Minority and Cisgender Youth

PURPOSE

Gender minority (GM) youth experience high rates of violence, and research on protective factors to reduce violence victimization and self-harm is lacking. The purpose of this study was to determine how family, school, peer, and community support influenced rates of violence victimization and self-harm among GM and cisgender adolescents.

METHODS

This research uses data from the 2017 New Mexico Youth Risk and Resiliency Survey (N = 18,451). The main independent variable was gender, dichotomized into GM and cisgender, and the secondary independent variables were family, school, community, and peer support. Dependent variables were sexual and dating violence, suicide attempts, and nonsuicidal self-injury. Logistic regression models were built for the four dependent variables, including demographics, support scores, and interaction terms between gender and support.

RESULTS

Six percent of high school students in New Mexico identified as GM are unsure of their gender. GM students experienced higher rates of violence and self-harm and lower levels of support than cisgender students. Among all students, family support was associated with lower odds of sexual violence and self-harm, while school support was associated with lower odds of dating violence and nonsuicidal self-injury. There were significant interactions between gender, violence, and support. The protective effects of support were less pronounced for GM students than for cisgender students.

CONCLUSIONS

Family and school support are associated with lower rates of some forms of violence and self-harm among adolescents. Additional support may be necessary to reduce harm among GM adolescents, who are at higher risk for violence and its sequelae.

Surveillance studies involving HIV testing are needed: Will at-risk youth participate?

OBJECTIVE

Adolescent males who have sex with males (AMSMs) account for high numbers of new HIV diagnoses. To date, surveillance data have been limited to diagnosed cases of HIV, resulting in an underestimation of risk and burden among AMSMs unwilling or unable to access HIV testing. This study identified facilitators and barriers to AMSMs' participation in future surveillance studies involving HIV testing.

METHOD

AMSMs (n = 198) aged 14 to 17 years participated. The majority identified as non-Hispanic White or Latinx, had a least 1 male sex partner, and self-reported HIV negative. Participants read an online survey beginning with a vignette describing a hypothetical HIV surveillance study requiring HIV testing. They then completed questions assessing likelihood to participate, perceived research benefits and risks, attitudes toward HIV risk, prior HIV health services, and parental awareness of sexual orientation.

RESULTS

Approximately 40% indicated strong willingness to participate. Willingness was positively related to perceived HIV risk, free access to HIV testing, counseling and referral if testing positive, confidentiality protections, and lack of access to a trusted physician. Having to tell others if one tested positive for HIV and requirements for guardian permission were significant participation barriers.

CONCLUSIONS

Inclusion of HIV testing in surveillance studies is essential for accurate estimation of HIV incidence and prevalence among AMSMs. Successful recruitment of sexual minority youth into sexual health surveillance research will require procedures tailored to youth's health care needs and concerns, including adequate HIV counseling, referral to treatment if seropositive, and attention to concerns regarding guardian permission. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Methodological Considerations for Advancing Research on the Health and Wellbeing of Sexual and Gender Minority Youth

Continued research with sexual and gender minority (SGM) youth is essential both to understand health disparities and to develop interventions targeting those disparities, but conducting rigorous, ethical research with these populations remains a substantial challenge. In addition to considerations for research with adolescents in general, such as utilizing developmentally appropriate measures and obtaining parental permission, factors unique to SGM youth must be addressed at every step of the research process. Defining the study population is complex, as is recruiting a sample once it is defined. Measurement is another challenge, given the paucity of measures developed for or validated with SGM samples. Key constructs, such as sexual orientation, gender identity, and family acceptance, are not amenable to randomization and involving minor participants' parents poses ethical concerns given the precarious home and safety situations that can arise from employing typical study procedures with youth who have a stigmatized identity. In this article, we examine some of these unique methodological challenges. Informed by theoretical and empirical literature, practical experience, and an ongoing dialogue with SGM youth themselves, we present a guide to best practices for ethical, productive research with SGM youth. By discussing existing approaches to studying SGM youth and suggesting innovative ways to approach the questions that remain, we hope to assist the research community in addressing methodological gaps to advance research on SGM youth in relation to families and schools.

For data's sake: dilemmas in the measurement of gender minorities

Gender-minority health disparity research is limited by binary gender measurement practices. This study seeks to broaden current discourse on gender identity measurement in the USA, including measurement adoption challenges and mitigation strategies, thereby allowing for better data collection to understand and address health disparities for people of all genders. Three data sources were used to triangulate findings: expert interviews with gender and sexuality research leaders; key-informant interviews with gender minorities in New Orleans, LA; and document analysis of relevant surveys, guides and commentaries. Ten key dilemmas were identified: 1) moving beyond binary gender construction; 2) conflation of gender, sex and sexual orientation; 3) emerging nature of gender-related language; 4) concerns about item sensitivity; 5) research fatigue among gender minorities; 6) design and analytical limitations; 7) categorical and procedural consistency; 8) pre-populated vs. open-field survey items; 9) potential misclassification; and 10) competing data collection needs. Researchers must continue working toward consensus concerning better practices is gender measurement and be explicit about their methodological choices. The existence of these dilemmas must not impede research on important health issues affecting gender minorities.

Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress

PURPOSE

As measures of birth-assigned sex, gender identity, and perceived gender presentation are increasingly included in large-scale research studies, data analysis approaches incorporating such measures are needed. Large samples capable of demonstrating variation within the transgender and gender diverse (TGD) community can inform intervention efforts to improve health equity. A population-based sample of TGD youth was used to examine associations between perceived gender presentation, bullying victimization, and emotional distress using two data analysis approaches.

METHODS

This secondary data analysis of the Minnesota Student Survey included 2168 9th and 11th graders who identified as "transgender, genderqueer, genderfluid, or unsure about their gender identity." Youth reported their biological sex, how others perceived their gender presentation, experiences of four forms of bullying victimization, and four measures of emotional distress. Logistic regression and multifactor analysis of variance (ANOVA) were used to compare and contrast two analysis approaches.

RESULTS

Logistic regressions indicated that TGD youth perceived as more gender incongruent had higher odds of bullying victimization and emotional distress relative to those perceived as very congruent with their biological sex. Multifactor ANOVAs demonstrated more variable patterns and allowed for comparisons of each perceived presentation group with all other groups, reflecting nuances that exist within TGD youth.

CONCLUSION

Researchers should adopt data analysis strategies that allow for comparisons of all perceived gender presentation categories rather than assigning a reference group. Those working with TGD youth should be particularly attuned to youth perceived as gender incongruent as they may be more likely to experience bullying victimization and emotional distress.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Barriers to Care Among Transgender and Gender Nonconforming Adults

Policy Points: Transgender and gender nonconforming (GNC) adults may experience barriers to care for a variety of reasons, including discrimination and lack of awareness by providers in health care settings. In our analysis of a large, population-based sample, we found transgender and GNC adults were more likely to be uninsured and have unmet health care needs, and were less likely to have routine care, compared to cisgender (nontransgender) women. Our findings varied by gender identity. More research is needed on transgender and GNC populations, including on how public policy and provider awareness affects health care access and health outcomes differentially by gender identity.

CONTEXT

Very little population-based research has examined health and access to care among transgender populations. This study compared barriers to care between cisgender, transgender, and gender nonconforming (GNC) adults using data from a large, multistate sample.

METHODS

We used data from the 2014-2015 Behavioral Risk Factor Surveillance System to estimate the prevalence of having no health insurance, unmet medical care needs due to cost, no routine checkup, and no usual source of care for cisgender women (n = 183,370), cisgender men (n = 131,080), transgender women (n = 724), transgender men (n = 449), and GNC adults (n = 270). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for each barrier to care while adjusting for sociodemographic characteristics.

FINDINGS

Transgender and GNC adults were more likely to be nonwhite, sexual minority, and socioeconomically disadvantaged compared to cisgender adults. After controlling for sociodemographic characteristics, transgender women were more likely to have no health insurance (OR = 1.60; 95% CI = 1.07-2.40) compared to cisgender women; transgender men were more likely to have no health insurance (OR = 2.02; 95% CI = 1.25-3.25) and no usual source of care (OR = 1.84; 95% CI = 1.18-2.88); and GNC adults were more likely to have unmet medical care needs due to cost (OR = 1.93; 95% CI = 1.02-3.67) and no routine checkup in the prior year (OR = 2.41; 95% CI = 1.41-4.12).

CONCLUSIONS

Transgender and GNC adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, and public policy or lack of awareness among health care providers on transgender-related health issues.

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.

Transgender Health: New Zealand's Innovative Statistical Standard for Gender Identity

The implementation of the New Zealand government's recently developed statistical standard for gender identity has led to, and will stimulate further, collection of gender identity data in administrative records, population surveys, and perhaps the census. This will provide important information about the demographics, health service use, and health outcomes of transgender populations to allow evidence-based policy development and service planning. However, the standard does not promote the two-question method, risking misclassification and undercounts; does promote the use of the ambiguous response category "gender diverse" in standard questions; and is not intersex inclusive. Nevertheless, the statistical standard provides a first model for other countries and international organizations, including United Nations agencies, interested in policy tools for improving transgender people's health.

Psychosocial Disparities Among Racial/Ethnic Minority Transgender Young Adults and Young Men Who Have Sex with Men Living in Detroit

Purpose: Transgender populations in the United States experience unique inequities in health and social well-being; however, they continue to be categorized with men who have sex with men (MSM) in HIV surveillance. To illustrate the differences in the lived realities of young MSM and transgender youth, we compare psychosocial outcomes across a sample of transgender and MSM youth from Detroit. Methods: Data for this study come from a community-based cross-sectional survey of young adults (ages 18-29) living in Detroit who identify as transgender and/or as cisgender young men who have sex with men (YMSM). Using participants' geographic location within the city of Detroit, we matched transgender participants (N=26) to YMSM (N=123) living in the same area, and compared the prevalence in risk and resilience indicators across the two groups. Results: Transgender participants were more likely than YMSM to experience socioeconomic vulnerability across several indicators, including lower educational attainment and workforce participation, greater residential instability, and higher lifetime experiences of transactional sex. Transgender participants were more likely than YMSM to report poorer health status, higher symptoms of depression and anxiety, and greater experiences of daily hassles and gender-related discrimination. Transgender participants did not differ from YMSM peers on health-promotive factors, including self-esteem, coping mastery, purpose in life, or social support. Conclusions: Our findings underscore the importance of addressing the social and economic inequities experienced by transgender young adults. Local- and national-level programmatic and policy interventions are recommended to alleviate the psychosocial vulnerability experienced by transgender young adults and to improve their health and social well-being.

Evaluating Public Health Interventions: 5. Causal Inference in Public Health Research-Do Sex, Race, and Biological Factors Cause Health Outcomes?

Counterfactual frameworks and statistical methods for supporting causal inference are powerful tools to clarify scientific questions and guide analyses in public health research. Counterfactual accounts of causation contrast what would happen to a population's health under alternative exposure scenarios. A long-standing debate in counterfactual theory relates to whether sex, race, and biological characteristics, including obesity, should be evaluated as causes, given that these variables do not directly correspond to clearly defined interventions. We argue that sex, race, and biological characteristics are important health determinants. Quantifying the overall health effects of these variables is often a natural starting point for disparities research. Subsequent assessments of biological or social pathways mediating those effects can facilitate the development of interventions designed to reduce disparities.

The Mental Health of Transgender Youth: Advances in Understanding

This review provides an update on the growing body of research related to the mental health of transgender youth that has emerged since the 2011 publication of the Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender people. The databases PubMed and Ovid Medline were searched for studies that were published from January 2011 to March 2016 in English. The following search terms were used: transgender, gender nonconforming, gender minority, gender queer, and gender dysphoria. Age limits included the terms youth, child, children, teenager*, and adolescen*. The combined search produced 654 articles of potential relevance. The resulting abstracts went through a tiered elimination system, and the remaining 15 articles, which presented quantitative data related to the prevalence of transgender youth and their mental health, were included in the present review. In addition to providing new estimates of the number of young people who identify as transgender (.17%-1.3%), studies since 2011 have shown that transgender youth have higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers. Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents. Recent research has demonstrated increased rates of psychiatric morbidity among transgender youth compared to their peers. Future work is needed to understand those youth who identify as gender nonbinary, improve methods to capture and understand diverse gender identities and related health disparities, and delineate the social determinants of such disparities.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Nurses' Knowledge About Transgender Patient Care: A Qualitative Study

This study explored practicing nurses' knowledge of the needs of transgender patients. Structured interviews were conducted with 268 nurses in the San Francisco Bay Area. This study focused on the responses to 1 item in the 16-item interview, "Describe health care issues that are particular to transgender patients." Three themes emerged from the data: discomfort, transition, and harsh consequences of being transgender. These findings revealed nurses' discomfort and lack of knowledge about transgender people and their health care needs. Nursing curricula must challenge the gender binary to better prepare nurses to provide quality care for patients of all genders.

Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women: Baseline Findings From Project LifeSkills

IMPORTANCE

Transgender youth, including adolescent and young adult transgender women assigned a male sex at birth who identify as girls, women, transgender women, transfemale, male-to-female, or another diverse transfeminine gender identity, represent a vulnerable population at risk for negative mental health and substance use outcomes. Diagnostic clinical interviews to assess prevalence of mental health, substance dependence, and comorbid psychiatric disorders in young transgender women remain scarce.

OBJECTIVE

To report the prevalence of mental health, substance dependence, and comorbid psychiatric disorders assessed via clinical diagnostic interview in a high-risk community-recruited sample of young transgender women.

DESIGN, SETTING, AND PARTICIPANTS

Observational study reporting baseline finding from a diverse sample of 298 sexually active, young transgender women aged 16 through 29 years (mean age, 23.4 years; 49.0% black, 12.4% Latina, 25.5% white, and 13.1% other minority race/ethnicity) and enrolled in Project LifeSkills, an ongoing randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015.

EXPOSURE

Transfeminine gender identity.

MAIN OUTCOMES AND MEASURES

Age- and site-adjusted prevalence and comorbidities of mental health and substance dependence disorders assessed via the Mini-International Neuropsychiatric Interview, including 1 or more diagnoses, 2 or more comorbid diagnoses, major depressive episode (current and lifetime), past 30-day suicidal risk (no/low risk vs moderate/high risk), past 6-month generalized anxiety disorder and posttraumatic stress disorder, and past 12-month alcohol dependence and nonalcohol psychoactive substance use dependence.

RESULTS

Of the 298 transgender women, 41.5% of participants had 1 or more mental health or substance dependence diagnoses; 1 in 5 (20.1%) had 2 or more comorbid psychiatric diagnoses. Prevalence of specific disorders was as follows: lifetime and current major depressive episode, 35.4% and 14.7%, respectively; suicidality, 20.2%; generalized anxiety disorder, 7.9%; posttraumatic stress disorder, 9.8%; alcohol dependence, 11.2%; and nonalcohol psychoactive substance use dependence, 15.2%.

CONCLUSIONS AND RELEVANCE

Prevalence of psychiatric diagnoses was high in this community-recruited sample of young transgender women. Improving access to routine primary care, diagnostic screening, psychotherapy, and pharmacologic treatments, and retention in care in clinical community-based, pediatric, and adolescent medicine settings are urgently needed to address mental health and substance dependence disorders in this population. Further research will be critical, particularly longitudinal studies across development, to understand risk factors and identify optimal timing and targets for psychosocial interventions.

Advancing methods for US transgender health research

PURPOSE OF REVIEW

This article describes methodological challenges, gaps, and opportunities in US transgender health research.

RECENT FINDINGS

Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities.

SUMMARY

Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

The Utility of an Online Convenience Panel for Reaching Rare and Dispersed Populations

Gaps in data collection systems, as well as challenges associated with gathering data from rare and dispersed populations, render current health surveillance systems inadequate to identify and monitor efforts to reduce health disparities. Using sexual and gender minorities we investigated the utility of using a large nonprobability online panel to conduct rapid population assessments of such populations using brief surveys. Surveys of the Google Android Panel (four assessing sexual orientation and one assessing gender identity and sex assigned at birth) were conducted resulting in invitation of 53,739 application users (37,505 of whom viewed the invitation) to generate a total of 34,759 who completed screening questions indicating their sexual orientation, or gender identity and sex at birth. Where possible we make comparisons to similar data from two population-based surveys (NHIS and NESARC). We found that 99.4% to 100.0% of respondents across our Google Android panel samples completed the screening questions and 97.8% to 99.2% of those that consented to participate in our surveys indicated they were “OK” with the content of surveys that assessed sexual orientation and sex/gender. In our Google Android panel samples there was a higher percentage of sexual minority respondents than in either NHIS or NESARC with 7.4% of men and 12.4% of women reporting gay, lesbian or bisexual identities. The proportion sexual minority was 2.8 to 5.6 times higher in the Google Android panel samples than was found in the 2012 NHIS sample, for men and women, respectively. The percentage of “transgender” identified individuals in the Google sample was 0.7%, which is similar to 0.5% transgender identified through the Massachusetts BRFSS, and using a transgender status item we found that 2.0% of the overall sample fit could be classified as transgender. The Google samples sometimes more closely approximated national averages for ethnicity and race than NHIS.

The Time Is Now: Attention Increases to Transgender Health in the United States but Scientific Knowledge Gaps Remain

Attention to transgender health has dramatically increased in the U.S. Scientific knowledge gaps in empirical research, however, remain and act as barriers to achieving transgender-related health equity. We conducted a search using PubMed and PsycINFO to identify gaps in empirical, peer-reviewed publications related to adult transgender health in the U.S. between 1981 and 2013. We synthesized these findings and commented on opportunities for improving health research. Reducing health disparities and advancing transgender-related health equity requires greater investment in research that addresses current gaps to more comprehensively respond to the diverse health needs of transgender people.

Characteristics of Transgender Residents of Massachusetts Cities With High HIV Prevalence

Geographic context can influence individual risk in populations disproportionately susceptible to HIV infection, such as transgender people. We examined factors associated with residing in Massachusetts cities with the highest HIV prevalence (geographic "hotspots") in a 2013 sample of 433 transgender adults who were not infected with HIV. Residing in hotspots was associated with older age, non-White race/ethnicity, low income, incarceration history, polydrug use, smoking, binge drinking, and condomless receptive anal sex during one's most recent sexual encounter with a partner who was assigned male sex at birth. Future research to understand the interpersonal and socio-structural factors that drive localized epidemics among transgender people is warranted.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late-stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act

PURPOSE OF REVIEW

To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities.

RECENT FINDINGS

Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities.

SUMMARY

The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.

Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health

This report describes the evolution of a Boston community health center's multidisciplinary model of transgender healthcare, research, education, and dissemination of best practices. This process began with the development of a community-based approach to care that has been refined over almost 20 years where transgender patients have received tailored services through the Transgender Health Program. The program began as a response to unmet clinical needs and has grown through recognition that our local culturally responsive approach that links clinical care with biobehavioral and health services research, education, training, and advocacy promotes social justice and health equity for transgender people. Fenway Health's holistic public health efforts recognize the key role of gender affirmation in the care and well-being of transgender people worldwide.

Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center

The sexual health of transgender adolescents and young adults who present for health care in urban community health centers is understudied. A retrospective review of electronic health record (EHR) data was conducted from 180 transgender patients aged 12-29 years seen for one or more health-care visits between 2001 and 2010 at an urban community health center serving youth in Boston, MA. Analyses were restricted to 145 sexually active transgender youth (87.3% of the sample). Laboratory-confirmed HIV and sexually transmitted infections (STIs) seroprevalence, demographics, sexual risk behavior, and structural and psychosocial risk indicators were extracted from the EHR. Analyses were descriptively focused for HIV and STIs. Stratified multivariable logistic regression models were fit for male-to-female (MTF) and female-to-male (FTM) patients separately to examine factors associated with any unprotected anal and/or vaginal sex (UAVS). The mean age was 20.0 (SD=2.9); 21.7% people of color, 46.9% white (non-Hispanic), 21.4% race/ethnicity unknown; 43.4% MTF, and 56.6% FTM; and 68.3% were on cross-sex hormones. Prevalence of STIs: 4.8% HIV, 2.8% herpes simplex virus, 2.8% syphilis, 2.1% chlamydia, 2.1% gonorrhea, 2.8% hepatitis C, 1.4% human papilloma virus. Only gonorrhea prevalence significantly differed by gender identity (MTF 2.1% vs. 0.0% FTM; p=0.046). Nearly half (47.6%) of the sample engaged in UAVS (52.4% MTF, 43.9% FTM, p=0.311). FTM more frequently had a primary sex partner compared to MTF (48.8% vs. 25.4%; p=0.004); MTF more frequently had a casual sex partner than FTM (69.8% vs. 42.7% p=0.001). In multivariable models, MTF youth who were younger in age, white non-Hispanic, and reported a primary sex partner had increased odds of UAVS; whereas, FTM youth reporting a casual sex partner and current alcohol use had increased odds of UAVS (all p<0.05). Factors associated with sexual risk differ for MTF and FTM youth. Partner type appears pivotal to understanding sexual risk in transgender adolescents and young adults. HIV and STI prevention efforts, including early intervention efforts, are needed in community-based settings serving transgender youth that attend to sex-specific (biological) and gender-related (social) pathways.

Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study

PURPOSE

Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exist to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the present study aimed to fill this gap.

METHODS

A retrospective cohort study of electronic health record data from 180 transgender patients aged 12-29 years seen between 2002 and 2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM with MTF youth on mental health outcomes.

RESULTS

The sample (N = 360) had a mean age of 19.6 years (standard deviation, 3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared with cisgender matched controls, transgender youth had a twofold to threefold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p < .05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use.

CONCLUSIONS

Transgender youth were found to have a disparity in negative mental health outcomes compared with cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.

Prevalence and correlates of substance use among trans female youth ages 16-24 years in the San Francisco Bay Area

BACKGROUND

Substance use is highly prevalent among transgender (trans*) females and has been associated with negative health outcomes, including HIV infection. Little is known about psychosocial risk factors that may influence the onset of substance use among trans*female youth, which can contribute to health disparities during adulthood.

METHODS

We conducted a secondary data analysis of a study on HIV risk and resilience among trans*female youth (N=292). Prevalence of substance use was assessed and multivariable logistic regression models were used to examine the relationship between posttraumatic stress disorder (PTSD), psychological distress, gender-related discrimination, parental drug or alcohol problems (PDAP) and multiple substance use outcomes.

RESULTS

Most (69%) of the trans*female youth reported recent drug use. In multivariable analyses, those with PTSD had increased odds of drug use [AOR=1.94 (95% CI=1.09-3.44)]. Those who experienced gender-related discrimination had increased odds of drug use [AOR=2.28 (95% CI=1.17-4.44)], drug use concurrent with sex [AOR=2.35 (95% CI=1.11-4.98)] and use of multiple drugs [AOR=3.24 (95% CI=1.52-6.88)]. Those with psychological distress had increased odds of using multiple heavy drugs [AOR=2.27 (95% CI=1.01-5.12)]. Those with PDAP had increased odds of drugs use [AOR=2.62 (95% CI=1.43-4.82)], drug use concurrent with sex [AOR=2.01 (95% CI, 1.15-3.51)] and use of multiple drugs [AOR=2.10 (95% CI=1.22-3.62)].

CONCLUSIONS

Substance use is highly prevalent among trans*female youth and was significantly associated with psychosocial risk factors. In order to effectively address substance use among trans*female youth, efforts must address coping related to gender-based discrimination and trauma. Furthermore, structural level interventions aiming to reduce stigma and gender-identity discrimination might also be effective.

The case for the World Health Organization's Commission on Social Determinants of Health to address gender identity

We analyzed the case of the World Health Organization's Commission on Social Determinants of Health, which did not address gender identity in their final report. We argue that gender identity is increasingly being recognized as an important social determinant of health (SDH) that results in health inequities. We identify right to health mechanisms, such as established human rights instruments, as suitable policy tools for addressing gender identity as an SDH to improve health equity. We urge the World Health Organization to add gender identity as an SDH in its conceptual framework for action on the SDHs and to develop and implement specific recommendations for addressing gender identity as an SDH.

Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults

Background

A barrier to monitoring the health of gender minority (transgender) populations is the lack of brief, validated tools with which to identify participants in surveillance systems.

Methods

We used the Growing Up Today Study (GUTS), a prospective cohort study of U.S. young adults (mean age = 20.7 years in 2005), to assess the validity of self-report measures and implement a two-step method to measure gender minority status (step 1: assigned sex at birth, step 2: current gender identity). A mixed-methods study was conducted in 2013. Construct validity was evaluated in secondary data analysis of the 2010 wave (n = 7,831). Cognitive testing interviews of close-ended measures were conducted with a subsample of participants (n = 39).

Results

Compared to cisgender (non-transgender) participants, transgender participants had higher levels of recalled childhood gender nonconformity age < 11 years and current socially assigned gender nonconformity and were more likely to have ever identified as not completely heterosexual (p < 0.001). No problems with item comprehension were found for cisgender or gender minority participants. Assigned sex at birth was interpreted as sex designated on a birth certificate; transgender was understood to be a difference between a person’s natal sex and gender identity. Participants were correctly classified as male, female, or transgender.

Conclusions

The survey items performed well in this sample and are recommended for further evaluation in languages other than English and with diverse samples in terms of age, race/ethnicity, and socioeconomic status.