Living on the extreme margin: social exclusion of the transgender population (hijra) in Bangladesh

Impact of legal recognition on the lives of the third gender: A study in Khulna district of Bangladesh

The third gender, popularly known as 'hijra', is a gender non-conforming person residing in Bangladesh. The government of Bangladesh granted legal recognition (LR) in 2013 to acknowledge them as a third gender. Thus, using an exploratory qualitative inquiry, the study sought to understand how LR affected the lives of the third gender community in the Khulna district of Bangladesh. Thirteen participants were selected following snowball sampling, and data were collected using in-depth interviews and key informant interviews. In the domain of socio-cultural dynamics, we found that the LR had enhanced the social participation of the third gender community and given them a sense of identity. On the contrary, within the domain of economic lives, the LR has not been able to change their economic situation. Moreover, in the third domain, we observed an improved situation for the third gender population in their right to vote and political participation, but in accessing healthcare facilities, inheritance, and legal services, LR remained unsatisfactory. The study recommends promoting acceptance and reducing social stigma towards the third gender community through awareness campaigns, providing professional training programs to enable their financial independence, and enacting laws to protect their rights in Bangladesh.

Quality of life and disease perceptions in caregivers of children with Congenital Adrenal Hyperplasia

Background

Congenital adrenal hyperplasia (CAH) is a chronic disorder requiring lifelong therapy. False perceptions, poor knowledge, and social isolation adversely affect the psychosocial health and quality of life of patients and caregivers. The study was undertaken to ascertain the quality of life of caregivers of children with CAH.

Method

A hospital-based cross-sectional study enrolled caregivers of children diagnosed with CAH where newborn screening was unavailable. Quality of life (QoL) was measured using the WHO-QoL-BREF questionnaire to compare physical, psychological health, social relationships, and environment.

Results

Eighteen children with CAH (9 males), 14 salt-wasting, and 4 simple virilizing CAH with median (IQR) age of 4.3 (2.6, 9.8) years and a follow-up period of 3.8 (1.3, 8.4) years were enrolled. Out of 18 caregivers, 6 were fathers and 12 mothers with a mean (SD) age of 38 (8) years. The mean (SD) of the total score was 69.2 (10.6); physical, psychological, environmental, and social domain were 69.8 (15.1), 57 (12.6), 64 (14.5), and 65 (9.9), respectively. Physical, psychological, and environmental domain scores were significantly higher in upper-middle than lower-middle socioeconomic strata (P < 0.05) and similar between salt-wasting and simple virilizing phenotypes. There was no significant correlation between QoL scores and duration of disease (r = 0.257, P = 0.44). Parents of 7 (38%) patients discussed disease with extended families or neighbors, but none of the school teachers were informed. Death (56%), social acceptance (27%), and infertility (18%) were the major concerns acknowledged.

Conclusion

The study reflects the suboptimal quality of life in caregivers of children with CAH. There was no correlation of the duration of disease with the QoL scores. Psychological and social relationship scores were poorest, indicating the need to creating more awareness to remove social taboos associated with this disease.

Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh

INTRODUCTION

In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs.

METHODS

This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks.

RESULTS

This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges.

CONCLUSION

The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.

Community based peer-led TB screening intervention: an innovative approach to increase TB knowledge, presumptive case identification, and referral among sexual minority people in urban Bangladesh

INTRODUCTION

One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh.

METHODS

This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches.

RESULTS

The 'Six Steps in Quality Intervention Development' framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators.

CONCLUSION

This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program.

"As a Trans Person You Don't Live. You Merely Try to Survive and Apologize Every Day for Who You Are" - Discrimination Experiences Among Trans Individuals in Greece"

This qualitative study sheds light on an issue very little research has been conducted on so far, the discrimination trans people in Greece are subjected to every day. The findings presented in this paper are part of a larger study focusing on trans persons' life experiences in contemporary Greece. Eleven participants identified various discrimination areas, employment, education, family, romantic relationships and daily life; participants also pointed out specific measures that would contribute to the improvement of their life. Findings are discussed in relation to measures toward eliminating discrimination against trans persons such as the improvement of gender recognition legislation, an increase in general education regarding gender identity issues and the need for transgender-focused research.

The Third Gender in a Third World Country: Major Concerns and the "AIIMS Initiative"

With a population dividend of around 1.3 billion, India is the largest democracy in the world that encompasses "unity in diversity". The kaleidoscope of the socio-cultural fabric comprises the transgender population too, which has a historical context dating back millennia and also plays a vital role as described in Hindu scriptures. The Indian transgender person's community shows a variety of gender identities and sexual orientations, which is unlikely from the West, forming a culturally unique gender group. In India, transgender persons were recognised as the 'third gender' in 2014. The third gender population of India is marginalised to a great extent in every sector. Often, transgender persons have been the subjects of sociology, psychology, and health issues. There was a dearth of data regarding their major health problems including bone health, which has not been reported in India and elsewhere before this study. Through a prospective cross-sectional study design, we aimed to determine the current health status of transgender persons with a special emphasis on bone health. Descriptive statistics were used for data analysis. The preliminary results of the study show poor bone health in the transgender population of India. The majority of transgender persons have low bone mineral density (BMD) at a much young age, even before the achievement of their peak bone mass. The health status of the transgender population in India is poor overall. Transgender persons have many impediments to optimal healthcare that requires holistic care. This study presents the current health challenges of the transgender population with a special emphasis on their bone health status as 'AIIMS initiative'. This study also shows transgender persons human rights needs to be explicitly discussed. The stakeholders of social policies require an urgent attention to unfold the major concerns encompassing transgender persons.

Adapting Psychiatric Case History Taking Practices for Indigenous Transgender Communities

While there is ample sociological or anthropological insight into the lives of Hijra persons in India, very little of it has been utilized in praxis for making mental health-care spaces Hijra-inclusive. Dominant discourses in Western psychiatry fail to tend to this community, predominantly because of its colonial gaze, inability to think beyond binaries, fancy to put “gender nonconformity” into diagnostic labels, and lack of intersectional focus and culture sensitivity. This is corroborated with remarkable service underutilization in this group as a parallel reality. Case history taking is an important part of any mental health intervention. In this article, the author shall attempt to delineate how psychiatric case history taking may be adapted to the needs of potential Hijra clients through ethnographic input from their lives. These provocations were initially shared by the author at the virtual Criposium Conference, 2020, organized jointly by King’s College London Disability+Intersectionality Reading Group and SOAS Crip Feminist Reading Group.

HIV/AIDS-Related risk behaviors, HIV prevalence, and determinants for HIV prevalence among hijra/transgender people in India: Findings from the 2014-2015 integrated biological and behavioural surveillance

Background

Hijra or transgender (H/TG) people are significantly affected by HIV in India. HIV prevalence among H/TG is the second highest after people who inject drugs. Effective interventions require understanding about various risk behaviors and associated factors for high prevalence.

Objectives

This study analyzes the known risk behaviors and vulnerabilities of HIV-positive and HIV-negative H/TG people to identify the determinants of HIV seropositivity in this high-risk group.

Methods

Using secondary data from India's 2014 to 2015 Integrated Biological and Behavioural Surveillance survey, this analysis was conducted among 3325 H/TG people across seven states. Probability-based sampling methods were used to recruit H/TG people. Informed consent was obtained for the collection of behavioral information and blood samples for HIV testing. Multivariable binary logistic regression analysis was undertaken to identify the determinants of HIV seropositivity.

Results

HIV prevalence for this group of respondents was 9.5%. Multivariable analysis of survey data revealed higher odds of HIV infection if H/TG had regular male partners (adjusted odds ratio [AOR]: 1.81, confidence interval [CI]: 1.07-3.06), were living in the states of Maharashtra (AOR: 6.08, CI: 3.02-12.22) and Odisha (AOR: 2.91, CI: 1.05-8.06), and were members of self-help groups (AOR: 2.08, CI: 1.04-4.14). None of the demographic or behavioral correlates of risk were found to be associated with HIV infection.

Conclusion

The findings suggest that community and structural factors, which are inadequately covered in surveys such as IBBS, play a more important role than individual behavioral factors.

Dispositional optimism and suicide among trans and gender diverse adults

Trans and gender diverse adults are at increased suicide risk. Optimism protects against suicide across multiple populations. Applying the Interpersonal-Psychological Theory of Suicide (IPTS), we examined both factors among 237 adults recruited via social media and online platforms, 79.3% of whom reported serious suicide ideation. Dispositional optimism predicted suicidal ideation and behaviors (SIB), but did not moderate the relationship between the IPTS components and SIB. After controlling for depressive symptoms, hormone therapy and gender-affirming surgery did not predict SIB. Promoting dispositional optimism within a therapeutic framework may reduce SIB in this vulnerable population.

The Effects of Methamphetamine Use on the Sexual Lives of Gender and Sexually Diverse People in Dhaka, Bangladesh: A Qualitative Study

Methamphetamine use has increased among gender and sexually diverse people in several countries, including Bangladesh. This study aimed to explore the effects of methamphetamine on the sexual lives of these people in Dhaka, Bangladesh. An exploratory qualitative study was conducted, comprising 30 in-depth interviews with gender and sexually diverse people including males having sex with males, male sex workers, and transgender women (hijra) under HIV intervention coverage. Ten key informant interviews were also conducted with individuals who have expertise in relevant disciplines such as drug use, harm reduction, and HIV and AIDS. Digitally recorded data were manually analyzed under the thematic analysis framework. Findings indicated that many participants reported that methamphetamine brought changes in their sexual lives such as increased sexual drive, engagement in group sex, the increased ability to perform serial sex, transactional sex, impulsive and coercive sex, initiation and switching of male-to-male sexual practices, and limited condom use. Key informants noted that there is a dearth of methamphetamine-related services in Bangladesh. Methamphetamine use was found to lead to diverse effects on the sexual lives of gender and sexually diverse people, thus making it a driving force for shaping sexual practices and, hence, sexual risks. Therefore, it is essential for policy-level stakeholders and program managers to consider the risks of methamphetamine use due to their negative ramifications on sexual health, including HIV risks.

Lives of Gender Incongruent Community: An Indian Subset Chants "All is Well"

CONTEXT

Gender incongruent individuals are exposed to unique stressors as a result of their minority social position. Poor social support has a further adverse impact on the lives and wellbeing of gender incongruent individuals. There is a paucity of scientific data from India on the socioeconomic status (SES) of gender incongruent community.

AIMS

Aim of the study is to understand and estimate the social support, wellbeing, and SES of gender incongruent individuals in Eastern India.

SUBJECTS AND METHODS

Data of 120 gender incongruent patients from the endocrinology outpatient department of a tertiary care hospital in eastern India were collected. We looked at demographic characteristics, social support, underlying psychiatric comorbidities, and SES. SES was calculated by the Kuppuswamy's socioeconomic status (KSS) scale based on occupation, education, and income.

STATISTICAL ANALYSIS USED

Microsoft Word and Excel were used to generate tables.

RESULTS

Most of the gender incongruent individuals were transfeminine. Almost half of them had no history of addiction. Most of them had good support from family and friends and very few (only 3%) had mental health problems. Calculation by KSS scale showed most of the study population lay in the upper middle or lower middle socioeconomic class.

CONCLUSIONS

Strong support from friends and family appears a key factor for protection against psychiatric comorbidities and an all-round impact on the lives and wellbeing of the study population.

Barriers in access to healthcare services for individuals with disorders of sex differentiation in Bangladesh: an analysis of regional representative cross-sectional data

Background

Worldwide people in disorder of sex development (DSD) faces multiple barriers while seeking their social rights, particularly healthcare services. We aimed to explore the healthcare opportunities available to them, using patterns of healthcare utilization and difficulties faced by DSD population in accessing healthcare services in Bangladesh.

Methods

Data from a total of 945 DSD population and 71 medical staff were analyzed, collected from three major divisions (Dhaka, Chittagong, and Rajshahi) in Bangladesh during the period of January to December of 2017. A structured questionnaire was used to collect data via face-to-face interviews. Descriptive statistic was used to determine the frequencies of the visit by the DSD population in healthcare facilities as well as to analyze difficulties experienced by the DSD population in getting healthcare services. Multivariate regression analysis was used to explore the association between perceived barriers in getting healthcare services and failures of the DSD population to receive the healthcare services.

Results

Present data revealed that around 80% of DSD population sought healthcare services from government healthcare facilities, where the overall success rate in getting healthcare services was less than 50%. The DSD population reported a number of reasons for failures in getting healthcare services, including non-friendly interaction by non-clinical hospital’s staff, non-friendly interaction by physicians, public fright as general people do not want to mingle with a DSD person, undesirable excess public interest in DSD individuals, and limitation of the treatment opportunities of hospitals to merely male or female patients. Among the stated reasons, the most frequently reported reason was non-friendly interaction by physicians (50.27%), followed by undesirable excess public interest in DSD individuals (50.16%).

Conclusion

DSD population in Bangladesh have limited access to healthcare facilities and facing multiple barriers to get healthcare services. Initiatives from the government and social organizations are important to ensure their access to healthcare services.

The willingness to receive sexually transmitted infection services from public healthcare facilities among key populations at risk for human immunodeficiency virus infection in Bangladesh: A qualitative study

Background

In Bangladesh, community-based and peer-led prevention interventions for human immunodeficiency virus infection are provided to key populations (KPs) by drop-in centers (DICs), which are primarily supported by external donors. This intervention approach was adopted because public healthcare facilities were reportedly insensitive to the needs and culture of KPs, particularly with regard to the provision of sexually transmitted infection (STI) services. Nonetheless, in the absence of external funding, STI services need to be integrated into public healthcare systems.

Methods

A qualitative study was conducted in 2017 to understand the willingness of KPs to uptake the STI services of public healthcare facilities. Data were collected based on 34 in-depth interviews, 11 focus group discussions, and 9 key informant interviews. The social-ecological theoretical framework was used to analyze the data thematically and contextually.

Results

Most participants were either resistant or reluctant to uptake STI services from public healthcare facilities because of their previous firsthand experiences (e.g., disrespectful and judgmental attitudes and behaviors), perceived discrimination, anticipatory fear, and a lack of privacy. Very few participants who had visited these facilities to receive STI services were motivated to revisit them. Nevertheless, they emphasized their comfort in DICs over public healthcare facilities. Thus, it appears that KPs can be situated along a care-seeking continuum (i.e., resistance to complete willingness). Unless policymakers understand the context and reasons that underlie their movement along this continuum, it would be difficult to encourage KPs to access STI services from public healthcare facilities.

Conclusion

KPs’ willingness to uptake the STI services of public healthcare facilities depends not only on individual and community experiences but also on the nexus between socio-structural factors and health inequalities. Community mobilization and training about the needs and culture of KPs for healthcare professionals are essential. Therefore, addressal of a wide range of structural factors is required to motivate KPs into seeking STI services from public healthcare facilities.

Challenges faced by marginalized communities such as transgenders in Pakistan

Introduction

Stigmatization, social exclusion and consequent banishment from the society makes transgender's life even tougher; isolating, pushing and forcing them into inappropriate conducts/habits like selling sex. This study investigates the association of social exclusion/victimization with high-risk behaviors among transgender community of Rawalpindi and Islamabad (Pakistan).

Methods

Through a cross-sectional study design, a sample of 189 transgender community living in twin cities of Rawalpindi and Islamabad was selected using snowball sampling technique. A validated close ended questionnaire was used to estimate the high-risk behaviors. Multivariate logistic regression was used to explore the competing outcomes associated with suicidal risk, selling sex and substance abuse.

Results

Majority study participants 77.8% experienced physical attacks with institutional discrimination even higher (91.5%). Commercial sex work and drug abuse was reported in 39.2% and 37.6% respectively. The prevalence of suicide ideation was high (38.6%) however, suicide attempted rate was less (18.5%). In the multivariate logistic regression, compared to those with no risk, being physically attacked increased the odds of both attempting (OR=2.18) and contemplating suicide and selling sex (OR=4.10). Nevertheless, the relative impact of institutional victimization on suicidal behavior was higher among those who were targeted on the basis of their gender identity or expression (AOR = 6.20, CI = 1.58-24.29, p=0.009).

Conclusion

The transgender community is socially excluded by the Pakistani society where they experience high levels of physical abuse and face discriminatory behavior in daily life. Such attitudes make them vulnerable for risky behaviors; forcing them to become commercial sex workers, begging, drugs use and even suicidal ideation.

HIV, HCV, HBV, and syphilis among transgender women from Brazil: Assessing different methods to adjust infection rates of a hard-to-reach, sparse population

Different sampling strategies, analytic alternatives, and estimators have been proposed to better assess the characteristics of different hard-to-reach populations and their respective infection rates (as well as their sociodemographic characteristics, associated harms, and needs) in the context of studies based on respondent-driven sampling (RDS). Despite several methodological advances and hundreds of empirical studies implemented worldwide, some inchoate findings and methodological challenges remain. The in-depth assessment of the local structure of networks and the performance of the available estimators are particularly relevant when the target populations are sparse and highly stigmatized. In such populations, bottlenecks as well as other sources of biases (for instance, due to homophily and/or too sparse or fragmented groups of individuals) may be frequent, affecting the estimates.In the present study, data were derived from a cross-sectional, multicity RDS study, carried out in 12 Brazilian cities with transgender women (TGW). Overall, infection rates for HIV and syphilis were very high, with some variation between different cities. Notwithstanding, findings are of great concern, considering the fact that female TGW are not only very hard-to-reach but also face deeply-entrenched prejudice and have been out of the reach of most therapeutic and preventive programs and projects.We cross-compared findings adjusted using 2 estimators (the classic estimator usually known as estimator II, originally proposed by Volz and Heckathorn) and a brand new strategy to adjust data generated by RDS, partially based on Bayesian statistics, called for the sake of this paper, the RDS-B estimator. Adjusted prevalence was cross-compared with estimates generated by non-weighted analyses, using what has been called by us a naïve estimator or rough estimates.

Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study

INTRODUCTION

Discrimination related to gender identity may directly influence vulnerability to HIV through increased exposure to unprotected receptive anal intercourse (URAI). Little is known about the relationship between gender-based discrimination (GBD) and URAI with stable partners among transgender women.

METHODS

This mixed-methods research began with a cross-sectional survey conducted between 2014 and 2016 with transgender women in Salvador, the capital city in one of the poorest regions in Brazil. Respondent-driven sampling was used to recruit the study population. GBD was defined through Latent Class Analysis. Additionally, 19 semi-structured interviews with participants were transcribed and analyzed through thematic content analysis.

RESULTS

URAI with stable partners was commonly reported (37.3%). GDB was positively associated with URAI among stable partners (OR = 6.47; IC 95%: 1.67-25.02). The analysis of the interviews illustrated how GBD impacted transgender women in diverse ways. Experiences with GBD perpetrated by the family often initiated a trajectory of economic vulnerability that led many to engage in survival sex work. The constant experience with GBD contributed to participants feeling an immense sense of trust with their stable partners, ultimately diminished their desire to use condoms. Further, the high frequency of GBD contributed to poor mental health overall, though some participants said engagement in transgender advocacy efforts provided a vital source of resilience and support.

CONCLUSION

Our mixed-method study capitalizes upon the strengths of diverse data sets to produce a holistic understanding of GBD and URAI with stable partners. Furthermore, by confirming the association between greater GBD and URAI, we have demonstrated how GBD can impact condom negotiation in diverse relationships.

Transgender Associations and Possible Etiology: A Literature Review

Transgender or gender dysphoria has been defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as distress resulting from the incongruence between one's experienced gender and one's assigned gender, along with a persistent and strong desire to be of another gender, and accompanied by clinically significant distress. Adolescents referred for evaluation often want hormonal therapy and several among them also express a desire for gender reassignment surgery. Furthermore, evidence shows that adolescents and adults with gender dysphoria without a sex development disorder, before gender reassignments, are at increased risk for suicide. For this review, a search of the English language scientific literature was conducted using the PubMed database. This summary discusses the associations and comorbidities of gender dysphoria and reiterates the evidence that its etiology is multifactorial. Transsexualism involves prenatal neuroanatomical changes, has a psychiatric association, and is found to be more prevalent in conjunction with schizophrenia and autism spectrum disorders. Childhood adversities and neglect are also linked to having a transgender identity. Moreover, the evidence favors a genetic predisposition. Likewise, there seems to be a growing concern with regards to the relationship between endocrine disruptors and transsexuals as well as other gender minority populations. More research needs to be done to understand the exact pathways.

The paradox of recognition: hijra, third gender and sexual rights in Bangladesh

Hijra, the iconic figure of South Asian gender and sexual difference, comprise a publicly institutionalised subculture of male-bodied feminine-identified people. Although they have existed as a culturally recognised third gender for a very long time, it is only recently that hijra have been legally recognised as a third gender in several South Asian countries. This paper focuses on the transformation of this long-running cultural category of third gender into a legal category of third gender in Bangladesh, showing that the process of legal recognition has necessitated a simultaneous mobilisation of a discourse of disability in the constitution of hijra as citizens worthy of rights. While the international community views the recognition of a third gender as a progressive socio-legal advance in the obtaining of sexual rights in a Muslim majority Bangladesh, locally, hijra are understood as a special group of people born with 'missing' or ambiguous genitals delinked from desire. Furthermore, what was previously a trope of disfigurement based on putative genital status has now been transformed into a discourse of disability, a corollary to which several interest groups, namely the civil society, the state, international community and hijra themselves, have all been party.

Validation of Bengali perceived stress scale among LGBT population

BACKGROUND

Lesbian, gay, bisexual and transgender (LGBT) population encounter more stressful life circumstances compared to general population. Perceived Stress Scale (PSS) can be a useful tool for measuring their stress. However, psychometric properties of PSS have never been tested on LGBT population.

METHODS

This cross sectional study employed a two-stage sampling strategy to collect data from 296 LGBT participants from six divisional districts of Bangladesh. Exploratory (EFA) and confirmatory factor analysis (CFA) were carried out on PSS 10 along with analysis of reliability and validity.

RESULTS

EFA revealed a two-factor structure of PSS for LGBT population explaining 43.55% - 51.45% of total variance. This measurement model was supported by multiple fit indices during CFA. Acceptable Cronbach's alpha indicated internal consistency reliability and high correlations with Self Reporting Questionnaire 20 demonstrated construct validity of PSS 10 for LGBT population.

CONCLUSION

This study provided evidence of satisfactory psychometric properties of Bengali PSS 10 in terms of factor structure, internal consistency and validity among LGBT population.

The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

INTRODUCTION

Globally, transgender ("trans") women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population.

METHODS

Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout.

RESULTS

To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women.

CONCLUSIONS

In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence.

Serving transgender people: clinical care considerations and service delivery models in transgender health

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.

Transgender women, hormonal therapy and HIV treatment: a comprehensive review of the literature and recommendations for best practices

INTRODUCTION

Studies have shown that transgender women (TGW) are disproportionately affected by HIV, with an estimated HIV prevalence of 19.1% among TGW worldwide. After receiving a diagnosis, HIV-positive TGW have challenges accessing effective HIV treatment, as demonstrated by lower rates of virologic suppression and higher HIV-related mortality. These adverse HIV outcomes have been attributed to the multiple sociocultural and structural barriers that negatively affect their engagement within the HIV care continuum. Guidelines for feminizing hormonal therapy among TGW recommend combinations of oestrogens and androgen blockers. Pharmacokinetic studies have shown that certain antiretroviral therapy (ART) agents, such as protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and cobicistat, interact with ethinyl estradiol, the key oestrogen component of oral contraceptives (OCPs). The goal of this article is to provide an overview of hormonal regimens used by TGW, to summarize the known drug-drug interactions (DDIs) between feminizing hormonal regimens and ART, and to provide clinical care recommendations.

METHODS

The authors identified English language articles examining DDIs between oestrogen therapy, androgen blockers and ART published between 1995 and 2015 using PubMed, Cumulative Index to Nursing and Allied Health Literature and EBSCOhost.

RESULTS AND DISCUSSION

Published articles predominantly addressed interactions between ethinyl estradiol and NNRTIs and PIs. No studies examined interactions between ART and the types and doses of oestrogens found in feminizing regimens. DDIs that may have the potential to result in loss of virologic suppression included ethinyl estradiol and amprenavir, unboosted fosamprenavir and stavudine. No clinically significant DDIs were noted with other anti-retroviral agents or androgen blockers.

CONCLUSIONS

There are insufficient data to address DDIs between ART and feminizing hormone regimens used by TGW. There is an urgent need for further research in this area, specifically pharmacokinetic studies to study the direction and degree of interactions between oral, injectable and transdermal estradiol and ART. Clinicians need to be vigilant about possible interactions and monitor hormone levels if concerns arise. More research is also needed on the provision of hormone therapy and gender-affirming care on the long-term health outcomes of HIV-positive TGW.

Empowering communities and strengthening systems to improve transgender health: outcomes from the Pehchan programme in India

INTRODUCTION

Transgender populations face inequalities in access to HIV, health and social services. In addition, there is limited documentation of models for providing appropriately tailored services and social support for transgender populations in low- and middle-income countries. This paper presents outcomes of the Global Fund-supported Pehchan programme, which aimed to strengthen community systems and provide HIV, health, legal and social services to transgender communities across 18 Indian states through a rights-based empowerment approach.

METHODS

We used a pre- and post-intervention cross-sectional survey design with retrospective analysis of programmatic data. Using stratified sampling, we identified 268 transgender participants in six Indian states from a total of 48,280 transgender people served by Pehchan through 186 community-based organizations. We quantified the impact of interventions by comparing baseline and end line indicators of accessed health social and legal services. We also assessed end line self-efficacy and collective action with regard to social support networks.

RESULTS

There were significant increases in community-based demand and use of tailored health, legal, social and psychological services over the time of the Pehchan programme. We report significant increases in access to condoms (12.5%, p<0.001) and condom use at last anal sex with both regular (18.1%, p<0.001) and casual (8.1%, p<0.001) male partners. Access to HIV outreach education and testing and counselling services significantly increased (20.10%, p<0.001; 33.7%, p<0.001). In addition, significant increases in access to emergency crisis response (19.7%, p<0.001), legal support (26.8%, p<0.001) and mental health services (33.0%, p<0.001) were identified. Finally, we note that the Pehchan programme successfully provided a platform for the formation, collectivization and visibility of peer support groups.

CONCLUSIONS

The Pehchan programme's community involvement, rights-based collectivization and gender-affirming approaches significantly improved both demand and access to tailored HIV, health and social services for transgender individuals across India. Furthermore, the Pehchan programme successfully fostered both self-efficacy and collective identity and served as a model for addressing the unique health needs of transgender communities. Continued strengthening of health, social and community systems to better respond to the unique needs of transgender communities is needed in order to sustain these gains.

Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India

We examined the presence and co-occurrence of psychosocial health conditions (depression, frequent alcohol use, and victimisation) among men who have sex with men (MSM) and transgender (TG) women in India, and their cumulative association with sexual risk. A survey questionnaire was administered among a convenience sample of 600 participants (MSM = 300; TG women = 300) recruited through six non-governmental organisations in four states. Prevalences of the number of psychosocial health conditions among MSM were: none = 31.3%, one = 43%, two = 20%, and three = 5.7%; and among TG women: none = 9%; one = 35.33%, two = 38.33%, and three = 17.33%. In bivariate and multivariate models, these conditions were positively and additively related to sexual risk, providing evidence for a syndemic of psychosocial health conditions among MSM and TG women and their synergistic effect on sexual risk. In addition to the number of syndemic conditions, resilient coping and social support were significant predictors of sexual risk among MSM and TG women, respectively. HIV preventive interventions in India should screen for and address co-occurring psychosocial health conditions - experiences of violence, mental health issues, and alcohol use - among MSM and TG women.

Expanding tuberculosis case notification among marginalized groups in Bangladesh through peer sputum collection

Case notification rates of tuberculosis (TB) in Bangladesh remain poor despite a high burden of disease. Peer sputum collection among underserved populations was implemented to expand case notification and to provide socially empowering roles in society for often excluded members of marginalized populations. Over the 55 months of the evaluation, 32 587 members of key populations were screened for TB, with 1587 smear-positive TB cases detected. Broadening TB services at human immunodeficiency virus drop-in centers using peer sputum collection to target high-risk populations for TB may be an effective way to increase TB case notification among key populations in Bangladesh.

Factors associated with healthcare avoidance among transgender women in Argentina

Introduction

Transgender (TG) women in many settings continue to contend with barriers to healthcare, including experiences of stigma and discrimination. Argentina has a universal health care system and laws designed to promote healthcare access among TG women. However, little is known about barriers to healthcare access among TG women in this setting. The aim of this study was to explore individual, social-structural and environmental factors associated with healthcare avoidance among TG women in Argentina.

Methods

Data were derived from a 2013 nation-wide, cross-sectional study involving TG women in Argentina. We assessed the prevalence and factors associated with avoiding healthcare using multivariable logistic regression.

Results

Among 452 TG women included in the study, 184 (40.7%) reported that they avoided seeking healthcare because of their transgender identity. In multivariable analysis, factors positively associated with avoiding seeking healthcare were: having been exposed to police violence (adjusted odd ratio [aOR] = 2.20; 95% CI: 1.26 – 3.83), internalized stigma (aOR = 1.60, 95% CI: 1.02–2.51), having experienced discrimination by healthcare workers (aOR = 3.36: 95% CI: 1.25 – 5.70) or patients (aOR = 2.57; 95% CI: 1.58 – 4.17), and currently living in the Buenos Aires metropolitan area (aOR = 2.32; 95% CI: 1.44 – 3.76). In contrast, TG women with extended health insurance were less likely to report avoiding healthcare (aOR = 0.49; 95% CI: 0.26 – 0.93).

Conclusions

A high proportion of TG women in our sample reported avoiding healthcare. Avoiding healthcare was associated with stigma and discrimination in healthcare settings, as well as police violence experiences. Although further research is warranted, these finding suggests that socio-structural interventions tailored TG women needs are needed to improve access to healthcare among this population.

Enhancing benefits or increasing harms: community responses for HIV among men who have sex with men, transgender women, female sex workers, and people who inject drugs

Studies completed over the past 15 years have consistently demonstrated the importance of community-level determinants in potentiating or mitigating risks for the acquisition and transmission of HIV. Structural determinants are especially important in mediating HIV risk among key populations, including men who have sex with men, people who inject drugs, sex workers of all genders, and transgender women. The objective of this systematic review was to synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations. The results of the review suggest that although health communication programs represent community-level strategies that have demonstrated the effectiveness in increasing the uptake of HIV testing and decreasing the experienced stigma among people living with HIV, there are limited studies focused on key populations in low- and middle-income settings. Moreover, interpretation from the 22 studies that met inclusion and exclusion criteria reinforce the importance of the continued measurement of community-level determinants of HIV risks and of the innovation in tools to effectively address these risks as components of the next generation of the HIV response. Consequently, the next generation of effective HIV prevention science research must improve our understanding of the multiple levels of HIV risk factors, while programming for key populations must address each of these risk levels. Failure to do so will cost lives, harm communities, and undermine the gains of the HIV response.

Towards full citizenship: correlates of engagement with the gender identity law among transwomen in Argentina

Introduction

In May 2012, Argentina passed its “Gender Identity” Law, which aimed to address the legal invisibility, discrimination and marginalization that transgender individuals have historically faced. The aim of this study was to explore factors associated with engagement with the Gender Identity Law among transwomen living in Argentina.

Methods

Data were derived from a 2013 nationwide, cross-sectional study involving transwomen in Argentina. Using multivariate logistic regression, we assessed the prevalence and factors associated with acquiring a gender-congruent identity card within the first 18 months of enactment of the Gender Identity Law.

Results

Among 452 transwomen, 260 (57.5%) reported that they had obtained a new gender-congruent identity card. In multivariate analysis, factors positively associated with acquiring a new ID were: previously experiencing discrimination by healthcare workers (adjusted odd ratio [aOR] = 2.01, 95% CI: 1.27–3.20); having engaged in transition procedures (aOR = 3.06, 95% CI: 1.58–5.93); and having a job other than sex work (aOR = 1.81, 95% CI: 1.06–3.10). Foreign born transwomen were less likely to have obtained a new ID (aOR = 0.14, 95% CI: 0.06–0.33).

Conclusions

More than half of transwomen in our sample acquired a new gender-congruent ID within the first 18 months of enactment of the Gender Identity Law. However, access to and uptake of this right has been heterogeneous. In particular, our findings suggest that the most empowered transwomen may have been among the first to take advantage of this right. Although educational level, housing conditions, HIV status and sex work were not associated with the outcome, foreign-born status was a strong negative correlate of new ID acquisition. Therefore, additional efforts should be made in order to ensure that benefits of this founding policy reach all transwomen in Argentina.

Worldwide burden of HIV in transgender women: a systematic review and meta-analysis

BACKGROUND

Previous systematic reviews have identified a high prevalence of HIV infection in transgender women in the USA and in those who sell sex (compared with both female and male sex workers). However, little is known about the burden of HIV infection in transgender women worldwide. We aimed to better assess the relative HIV burden in all transgender women worldwide.

METHODS

We did a systematic review and meta-analysis of studies that assessed HIV infection burdens in transgender women that were published between Jan 1, 2000, and Nov 30, 2011. Meta-analysis was completed with the Mantel-Haenszel method, and random-effects modelling was used to compare HIV burdens in transgender women with that in adults in the countries for which data were available.

FINDINGS

Data were only available for countries with male-predominant HIV epidemics, which included the USA, six Asia-Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19·1% (95% CI 17·4-20·7) in 11 066 transgender women worldwide. In 7197 transgender women sampled in ten low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6-19·8). In 3869 transgender women sampled in five high-income countries, HIV prevalence was 21·6% (95% CI 18·8-24·3). The odds ratio for being infected with HIV in transgender women compared with all adults of reproductive age across the 15 countries was 48·8 (95% CI 21·2-76·3) and did not differ for those in low-income and middle-income countries compared with those in high-income countries.

INTERPRETATION

Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The meta-analysis showed remarkable consistency and severity of the HIV disease burden among transgender women.

FUNDING

Center for AIDS Research at Johns Hopkins and the Center for Public Health and Human Rights at the JHU Bloomberg School of Public Health.

Is social exclusion pushing the Pakistani Hijras (Transgenders) towards commercial sex work? a qualitative study

Background

The Hijra is a distinct type of gender role in South Asia where men act like women. This group of people is socially excluded by the general community, in terms of attainment of an opportunity for a socially productive life. Often this sort of deprivation forces these individuals towards professions like sex trade, in pursuit of sustenance, which as a consequence places them as a key block in the puzzle of an impending generalized HIV epidemic in Pakistan.

Methods

This study is a qualitative study, which involved 8 in-depth interviews and four focus group discussions, conducted in Rawalpindi and Islamabad (Pakistan) from February to April 2012. The data was audio taped and transcribed. Key themes were identified and built upon. The respondents were contacted through a gate keeper Hijra who was a member of the hijra community. Multiple interview sessions were conducted with each respondent.

Results

Two key categories of the Hijras were identified as Khusrapan and Zananapan, during the in-depth interview sessions. This initial information paved way for the four focus group discussions. The data was presented using key themes which were identified. The study participants explained their life histories to us which made it obvious that they had been socially excluded at many stages of their lives from performing normal social functions. This lack of occupational and educational opportunities pushed them towards entering the risky business of selling sex.

Conclusion

The transgender community is socially excluded by the Pakistani society which is leading them to indulge in commercial sex and putting their lives at risk. Prudent measures are needed to form community based organizations managed and led by hijra community and addressing their social exclusion and risky behaviors.

Sexually transmitted infections and risk behaviors among transgender persons (Hijras) of Pune, India

BACKGROUND

The objectives of this cross-sectional study were to determine the prevalence of HIV and sexually transmitted infections (STI) in Hijras (self-identified transgenders of South Asia), study associated risk factors, and compare the prevalence with that in heterosexual men and men having sex with men (MSM) in Pune, India, between 1993 and 2002.

METHODS

After informed consent, individuals attending 3 STI clinics were administered a questionnaire regarding their demographic, socioeconomic, and sexual behaviors. Blood samples were collected for STI and HIV diagnosis. Bivariate and multivariate analyses were performed to determine the correlates of HIV infection.

RESULTS

The prevalence of HIV (45.2% in Hijras vs 20% in heterosexual men vs 18.9% in MSM, P < 0.0001) and warts (10.3% vs 4.6% vs 7.0%; P = 0.004) was higher in Hijras as compared with heterosexual men and MSM; whereas that of genital ulcer disease (15.3% vs 32.6% vs 21.5%; P < 0.0001) and discharge (5.4% vs 13.6% vs 9.0%; P < 0.0001) was lower. Hijras were more likely to have received money for sex and have an earlier sexual debut than the comparison groups. In multivariate analysis, receiving money for sex (adjusted odds ratio: 4.49; P < 0.04) and having genital ulcer disease (odds ratio: 3.87; P < 0.08) were independently associated with high HIV prevalence in Hijras.

CONCLUSIONS

Considering the high HIV and STI burden, it is important to review current prevention strategies and stress the need to engage Hijra community members through appropriate targeted intervention programs.

Congenital adrenal hyperplasia: as viewed by parents of affected children in India--a pilot study

A spectrum of myths and misconceptions about congenital adrenal hyperplasia (CAH) is prevalent among the parents of affected children in India. The perceptions of parents may affect several aspects of these children's management, and to explore these perceptions we carried out a cross-sectional questionnaire-based descriptive study during May 2010. Twenty-eight individuals (17 males and 11 females), parents of 22 affected children aged < 5 years, completed the questionnaire. Their responses showed the prevalence among the parents of misconceptions about CAH. These misconceptions were resulting in potentially harmful practices, and in addition there was immense societal pressure on the families as a result of ignorance and myths about the disorder. There is a need for regular CAH education and interaction programs to provide an acceptable platform for the parents and patients, where their concerns can be expressed and shared and their requirements addressed appropriately by a multidisciplinary team.