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Greenwald ZR, Werb D, Feld JJ, Austin PC, Fridman D, Bayoumi AM, Gomes T, Kendall CE, Lapointe-Shaw L, Scheim AI, Bartlett SR, Benchimol EI, Bouck Z, Boucher LM, Greenaway C, Janjua NZ, Leece P, Wong WW, Sander B, Kwong JC. Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada. J Clin Epidemiol 2024:111332. [PMID: 38522754 DOI: 10.1016/j.jclinepi.2024.111332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/12/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada. STUDY DESIGN AND SETTING Data from cohorts of people with recent (past 12 month) injection drug use, including those participating in community-based research studies or seeking drug treatment were linked to health administrative data in Ontario from 1992-2020. We assessed the validity of algorithms to identify injection drug use over varying lookback periods (i.e., all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT). RESULTS Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts, 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, emergency department visit or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity, 94.2% specificity) and recent IDU (using 3 years lookback: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment. CONCLUSION Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of injection drug use in the population in which they are applied.
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Affiliation(s)
- Zoë R Greenwald
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
| | - Jordan J Feld
- Department of Medicine, University of Toronto, Toronto, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada; University Health Network, Toronto, Canada
| | - Peter C Austin
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Ahmed M Bayoumi
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Department of Medicine, University of Toronto, Toronto, Canada; Division of General Internal Medicine, St. Michael's Hospital, Unity Health Toronto,; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada
| | - Tara Gomes
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Ontario Drug Policy Research Network, Toronto, Canada
| | - Claire E Kendall
- ICES, Toronto, Canada; Bruyère Research Institute, Ottawa, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Department of Medicine, University of Toronto, Toronto, Canada; University Health Network, Toronto, Canada
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, United States; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Eric I Benchimol
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Zachary Bouck
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto. Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | - Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, Montreal, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Canada; Department of Epidemiology and Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada; Centre for Health Evaluation & Outcome Sciences, St Paul's Hospital Vancouver, Vancouver, Canada
| | - Pamela Leece
- Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - William Wl Wong
- ICES, Toronto, Canada; School of Pharmacy, University of Waterloo, Kitchener, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Beate Sander
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,; University Health Network, Toronto, Canada; Public Health Ontario, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; University Health Network, Toronto, Canada; Public Health Ontario, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
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Aghi K, Anderson BM, Castellano BM, Cunningham A, Delano M, Dickinson ES, von Diezmann L, Forslund-Startceva SK, Grijseels DM, Groh SS, Guthman EM, Jayasinghe I, Johnston J, Long S, McLaughlin JF, McLaughlin M, Miyagi M, Rajaraman B, Sancheznieto F, Scheim AI, Sun SED, Titmuss FD, Walsh RJ, Weinberg ZY. Rigorous science demands support of transgender scientists. Cell 2024; 187:1327-1334. [PMID: 38490174 DOI: 10.1016/j.cell.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024]
Abstract
To build a just, equitable, and diverse academy, scientists and institutions must address systemic barriers that sex and gender minorities face. This Commentary summarizes (1) critical context informing the contemporary oppression of transgender people, (2) how this shapes extant research on sex and gender, and (3) actions to build an inclusive and rigorous academy for all.
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Affiliation(s)
- Krisha Aghi
- Department of Integrative Biology and Physiology, UCLA, Los Angeles, CA, USA
| | | | | | | | - Maggie Delano
- Department of Engineering, Swarthmore College, Swarthmore, PA, USA
| | | | - Lexy von Diezmann
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, USA.
| | - Sofia Kirke Forslund-Startceva
- Experimental and Clinical Research Centre, a joint venture of Charité University Hospital and the Max Delbrück Centre, Berlin, Germany
| | - Dori M Grijseels
- Social Systems and Circuits Group, Max Planck Institute for Brain Research, Frankfurt am Main, Germany
| | - Sebastian S Groh
- Quality Enhancement Directorate, Cardiff Metropolitan University, Cardiff, UK
| | - Eartha Mae Guthman
- Princeton Neuroscience Institute, Princeton University, Princeton, NJ, USA; Center for Applied Transgender Studies, Chicago, IL, USA
| | - Izzy Jayasinghe
- School of Biosciences, The University of Sheffield, Sheffield, UK; Department of Molecular Medicine, University of New South Wales, Sydney, Australia
| | - Juliet Johnston
- Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Sam Long
- Denver Public Schools, Denver, CO, USA
| | - Jess F McLaughlin
- Department of Environmental Conservation, University of Massachusetts Amherst, Amherst, MA, USA
| | - Maeve McLaughlin
- Department of Microbiology, Genetics, and Immunology, Michigan State University, East Lansing, MI, USA.
| | - Miriam Miyagi
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA
| | - Bittu Rajaraman
- Departments of Biology and Psychology, Ashoka University, Sonipat, Haryana, India
| | - Fátima Sancheznieto
- Institute for Clinical and Translational Research, University of Wisconsin-Madison, Madison, WI, USA
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
| | - Simón E D Sun
- Center for Applied Transgender Studies, Chicago, IL, USA; Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA.
| | - F Dylan Titmuss
- Department of Applied Ocean Physics and Engineering, Woods Hole Oceanographic Institution, Woods Hole, MA, USA
| | - Reubs J Walsh
- Center for Applied Transgender Studies, Chicago, IL, USA; Department of Psychology, Faculty of Arts & Sciences, University of Toronto, Toronto, ON, Canada
| | - Zara Y Weinberg
- Department of Biochemistry & Biophysics, UCSF, San Francisco, CA, USA
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Scheim AI, Rich AJ, Zubizarreta D, Malik M, Baker KE, Restar AJ, van der Merwe LA, Wang J, Beebe B, Ridgeway K, Baral SD, Poteat T, Reisner SL. Health status of transgender people globally: A systematic review of research on disease burden and correlates. PLoS One 2024; 19:e0299373. [PMID: 38466747 PMCID: PMC10927095 DOI: 10.1371/journal.pone.0299373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality. DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis. RESULTS The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality. CONCLUSIONS AND IMPLICATIONS Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants. REGISTRATION PROSPERO CRD42021234043.
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Affiliation(s)
- Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, United States of America
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ashleigh J. Rich
- Department of Social Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Dougie Zubizarreta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Mannat Malik
- Department of Health Behaviour, Gillings School of Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Kellan E. Baker
- Whitman-Walker Institute, Washington, District of Columbia, United States of America
| | - Arjee J. Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Leigh Ann van der Merwe
- Social, Health and Empowerment Feminist Collective of Transgender Women of Africa (S.H.E.), East London, South Africa
| | - June Wang
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Bianca Beebe
- School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kathleen Ridgeway
- School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Stefan D. Baral
- Department of Epidemiology, School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sari L. Reisner
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Ghabrial MA, Scheim AI, Chih C, Santos H, Adams NJ, Bauer GR. Change in Finances, Peer Access, and Mental Health Among Trans and Nonbinary People During the COVID-19 Pandemic. LGBT Health 2023; 10:595-607. [PMID: 37347954 PMCID: PMC10712362 DOI: 10.1089/lgbt.2022.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Purpose: Due to structural transphobia, trans and nonbinary (TNB) individuals were particularly vulnerable to the negative effects of social isolation and financial instability resulting from COVID-19. The present study examined the effect of change in finances and access to TNB peer gatherings on anxiety and depression during the COVID-19 pandemic. Methods: Participants were 18 years and older (mean = 30) and completed prepandemic baseline (Fall 2019) and pandemic follow-up (Fall 2020) surveys. Multivariable regressions examined associations between mental health and change in (1) finances and (2) access to TNB peer gatherings (in person or online). Results: Of 780 participants, 50% reported that the COVID-19 pandemic had a negative impact on personal income and 58.3% reported negative impact on access to TNB peer gatherings. Depression and anxiety symptoms increased from prepandemic to follow-up, and most participants were above measurement cutoffs for clinical levels at both time points. Change in finances and access to TNB peer gatherings interacted with prepandemic depression scores to predict depression symptoms during the COVID-19 pandemic. For participants with high prepandemic depression scores, financial stability predicted pandemic depression scores comparable to that predicted by negative financial change. No interaction was found between these variables when predicting anxiety symptoms during the COVID-19 pandemic. Conclusion: Findings underscore the influence of inequality and prepandemic mental health when considering the impact of COVID-19 on wellbeing. Results suggest need for multifaceted programs and services, including financial support and meaningful TNB community engagement, to address barriers to health equity posed by systematic gender oppression.
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Affiliation(s)
- Monica A. Ghabrial
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Ayden I. Scheim
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Caiden Chih
- Mechanical and Industrial Engineering and University of Toronto, Toronto, Ontario, Canada
| | - Heather Santos
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Noah James Adams
- Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada
- Center for Applied Transgender Studies, Chicago, Illinois, USA
- Transgender Professional Association for Transgender Health, Canada
| | - Greta R. Bauer
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Institute for Sexual and Gender Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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5
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Jones J, Butler G, Woody M, Castel AD, Kulie P, Sheets M, Scheim AI, Reisner SL, Valencia R, Wang M, Stekler JD, Sullivan PS, Stephenson R. Preferences for and Experiences of an HIV-Prevention Mobile App Designed for Transmasculine People: Pilot Feasibility Trial and Qualitative Investigation. JMIR Form Res 2023; 7:e51055. [PMID: 37733430 PMCID: PMC10557014 DOI: 10.2196/51055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Transmasculine people are at risk for HIV; yet few HIV prevention interventions have been developed for this population. We adapted an existing HIV prevention smartphone app for cisgender men who have sex with men to meet the sexual health needs of transmasculine people. OBJECTIVE This study aims to assess the acceptability of the adapted app, Transpire, among transmasculine people living in Atlanta, Georgia, and Washington, DC, via in-depth interviews of participants in a pilot feasibility trial. METHODS Participants used the Transpire app for 3 months as part of a pilot study of the app. Eligible participants were aged 18-34 years. There were no eligibility criteria with respect to race and ethnicity, and most participants were non-Hispanic White. At the end of the follow-up, participants were invited to participate in web-based in-depth interviews to discuss their experiences using the app and feedback on design and content. Interviews were transcribed and coded using a constant comparative approach. Three main themes were identified: sexual behavior, app experiences and feedback, and pre-exposure prophylaxis. RESULTS Overall, participants found the app acceptable and thought that it would be a useful tool for themselves and their peers. Participants reported appreciating having a comprehensive information source available to them on their phones and reported learning more about HIV, sexually transmitted infections, and pre-exposure prophylaxis via the app. They also reported appreciating the inclusive language that was used throughout the app. Although the app included some resources on mental health and substance use, participants reported that they would have appreciated more resources and information in these areas as well as more comprehensive information about other health concerns, including hormone therapy. Representative quotes are presented for each of the identified themes. CONCLUSIONS There is a desire to have greater access to reliable sexual health information among transmasculine people. Mobile apps like Transpire are an acceptable intervention to increase access to this information and other resources. More evidence is needed, however, from more racially and ethnically diverse samples of transmasculine people.
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Affiliation(s)
- Jeb Jones
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Gareth Butler
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Meaghan Woody
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Amanda D Castel
- Department of Epidemiology, George Washington University, Washington, DC, DC, United States
| | - Paige Kulie
- Department of Epidemiology, George Washington University, Washington, DC, DC, United States
| | - Martha Sheets
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, United States
| | - Sari L Reisner
- Department of Epidemiology, Harvard University, Boston, MA, United States
| | - Rachel Valencia
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Minglun Wang
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Joanne D Stekler
- Division of Allergy & Infectious Diseases, University of Washington, Seattle, WA, United States
| | - Patrick S Sullivan
- Department of Epidemiology, Emory University, Atlanta, GA, United States
| | - Rob Stephenson
- Department of Systems Populations, and Leadership, University of Michigan, Ann Arbor, MI, United States
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Tran GM, Lachowsky N, Urbanoski KA, Scheim AI, Bauer GR. Correlates of hazardous alcohol drinking among trans and non-binary people in Canada: A community-based cross-sectional study. Drug Alcohol Depend 2023; 250:110872. [PMID: 37406573 DOI: 10.1016/j.drugalcdep.2023.110872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Transgender and non-binary people (TGNB) have a higher rate of heavy episodic drinking than cisgender people; however, extant knowledge about predictors of hazardous alcohol drinking (HAD) among different TGNB groups is limited. This study examined predictors of HAD in a national sample of TGNB people in Canada. METHODS Logistic regression models were fit to examine the effects of 1) minority stressors and 2) stress-buffering factors on the likelihood of HAD, stratified by gender, among 2324 TGNB individuals from the Trans PULSE Canada survey, a cross-sectional survey conducted in 2019 among trans and non-binary people aged 14+ in Canada. RESULTS Almost 17% of participants reported past-year HAD. Lifetime day-to-day and lifetime major discrimination were associated with higher odds of HAD in the full sample [(AOR=1.37, 95% CI: 1.30, 1.44) and (AOR=1.69, 95% CI: 1.55, 1.86) respectively], and across all gender groups. Social support was associated with lower odds of HAD in trans men, non-binary people assigned female at birth (NB-AFAB), and non-binary people assigned male at birth (NB-AMAB) groups, but with higher odds of HAD in the trans women group. Misgendering was associated with lower odds of HAD in trans men and NB-AFAB, but higher odds of HAD in trans women and NB-AMAB. Mixed effects of gender distress, gender positivity, and gender-affirming medical care were also reported across groups. CONCLUSION The study provided a more detailed understanding of the predictors of HAD across four TGNB groups. Public health interventions should focus on structural discrimination and social support for TGNB people.
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Affiliation(s)
- Gioi Minh Tran
- School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2, Canada; Center for Community Health Promotion, Suite 313-314, Block E1, Trung Tu Diplomatic Compound, Dong Da, Hanoi, Viet Nam.
| | - Nathan Lachowsky
- School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2, Canada; Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Avenue, Victoria, BCV8P 5C2, Canada
| | - Karen A Urbanoski
- School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2, Canada; Canadian Institute for Substance Use Research, University of Victoria, Technology Enterprise Facility Room 273, 2300 McKenzie Avenue, Victoria, BCV8P 5C2, Canada
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA19104, United States; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, Canada
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada; Institute for Sexual and Gender Health, University of Minnesota Medical School, 1300 South 2nd Street, Minneapolis, MN55455, United States
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7
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Wiginton JM, Maksut JL, Scheim AI, Zlotorzynska M, Sanchez TH, Baral SD. Intersecting Sexual Behavior and Gender Identity Stigmas Among Transgender Women in the United States: Burden and Associations with Sexual Health. AIDS Behav 2023:10.1007/s10461-023-04028-w. [PMID: 36952112 PMCID: PMC10034890 DOI: 10.1007/s10461-023-04028-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 03/24/2023]
Abstract
In the United States, a context of multiple marginalization shapes sexual health disparities experienced by transgender women. Using data from 396 transgender women with negative or unknown HIV status, we performed exploratory factor analysis on responses to gender identity and sexual behavior stigma items and regressed sexual health outcomes on extracted factors via modified Poisson regression with robust variance estimation. Overall, 97.2% of participants endorsed ≥ 1 gender identity stigma; 67.2% endorsed ≥ 1 sexual behavior stigma; and 66.9% endorsed ≥ 1 of each. Extracted factors included gender-identity social stigma, reflecting experiences related to family, fearfulness in public, and verbal harassment (α = 0.68); gender-identity institutional stigma/violence, reflecting experiences related to healthcare, police interactions, and interpersonal violence (α = 0.73); and global sexual behavior stigma, reflecting experiences related to family, friends, and healthcare, as well as police interactions, fearfulness in public, verbal harassment, and interpersonal violence (α = 0.83). Gender-identity social stigma was significantly, positively associated with testing for HIV and testing for sexually transmitted infections. Gender-identity institutional stigma/violence and global sexual behavior stigma were both significantly, positively associated with condomless anal sex, sex work, testing for HIV, testing for sexually transmitted infections, and use of HIV pre-exposure prophylaxis. Stigma-mitigation remains critical to improve quality of life and sexual health for transgender women in the United States.
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Affiliation(s)
- John Mark Wiginton
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California-San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
- San Diego State University, San Diego, CA, USA.
| | - Jessica L Maksut
- Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Ayden I Scheim
- Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market St, Philadelphia, PA, 19104, USA
| | - Maria Zlotorzynska
- Rollins School of Public Health, Emory University, 1581 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Travis H Sanchez
- Rollins School of Public Health, Emory University, 1581 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Stefan D Baral
- Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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8
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Greenwald ZR, Bouck Z, McLean E, Mason K, Lettner B, Broad J, Dodd Z, Nassau T, Scheim AI, Werb D. Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis. J Viral Hepat 2023; 30:160-171. [PMID: 36461705 DOI: 10.1111/jvh.13780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 12/09/2022]
Abstract
Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.
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Affiliation(s)
- Zoë R Greenwald
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Zachary Bouck
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Elizabeth McLean
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | | | - Jennifer Broad
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - Zoë Dodd
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tanner Nassau
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, California, USA
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9
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Lacombe-Duncan A, Kattari SK, Kattari L, Scheim AI, Misiolek BA. Sexually transmitted infection testing among transgender and non-binary persons: results of a community-based cross-sectional survey. Sex Health 2023; 20:87-91. [PMID: 36347262 DOI: 10.1071/sh22128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/15/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Studies show higher rates of sexually transmitted infections (STIs) among transgender (trans) and non-binary (TNB) persons compared with the general population. Scant studies have examined non-HIV STI testing (henceforth referred to as STI testing); fewer inclusive of trans men and non-binary persons. We characterised the prevalence of STI testing and time since last STI test and gender-based differences in these outcomes among TNB persons. METHODS Data were analysed from a 2018 community-based participatory cross-sectional survey (n =528). Prevalence of lifetime STI testing history and time since last STI test were reported overall and compared across genders (trans men, trans women, non-binary assigned female at-birth, non-binary assigned male at-birth) using Chi-squared, then bivariable and multivariable logistic regression analyses to compare lifetime STI testing history (ever vs never) across sociodemographic and health care characteristics. RESULTS Most (n =425; 80.5%) participants reported having ever had an STI test; over half (59.8%) ever tested had tested within the past year. Bivariate analyses showed no significant gender differences in lifetime STI testing history (P =0.298) or time since last STI test (P =0.118). In a multivariable model, higher age, reporting multiple committed partners (vs single/divorced), known HIV status, and ever receiving information about pre-exposure prophylaxis (PrEP) were positively associated with ever having had an STI test, whereas Latinx race/ethnicity (vs white) was negatively associated. CONCLUSIONS Findings showed high rates of lifetime STI testing and recent testing, with no gender-based differences. Never testing rates were concerning considering screening recommendations. Broad based (non-gender specific) TNB-focused interventions may be warranted to increase uptake.
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Affiliation(s)
| | - Shanna K Kattari
- University of Michigan, School of Social Work, Ann Arbor, MI, USA; and University of Michigan, Department of Women's and Gender Studies, Ann Arbor, MI, USA
| | - Leonardo Kattari
- Michigan State University, School of Social Work, East Lansing, MI, USA
| | - Ayden I Scheim
- Drexel University, Dornsife School of Public Health, Philadelphia, PA, USA
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10
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Tran NK, Martinez O, Scheim AI, Goldstein ND, Welles SL. Perceived Barriers to and Facilitators of Long-Acting Injectable HIV PrEP Use Among Black, Hispanic/Latino, and White Gay, Bisexual, and Other Men Who Have Sex With Men. AIDS Educ Prev 2022; 34:365-378. [PMID: 36181495 DOI: 10.1521/aeap.2022.34.5.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was recently approved for HIV prevention as an alternative to daily oral PrEP. We explored preferences and attitudes toward LAI-PrEP among Black, Hispanic/Latino, and White gay, bisexual, and other men who have sex with men (GBM) using focus groups (n = 13) and in-depth interviews (n = 17). Participants expressed differing levels of interest in LAI-PrEP. While important benefits of LAI-PrEP included convenience, provider-facilitated PrEP discussion, and expansion of PrEP options, participants raised concerns about treatment efficacy and side effects, discomfort with needles/injections, cost, and frequency of clinic visits. Our findings highlight ongoing challenges with accessing HIV-prevention tools and provide guidance for developing strategies to enhance LAI-PrEP uptake among GBM.
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Affiliation(s)
- Nguyen K Tran
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Omar Martinez
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Neal D Goldstein
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Seth L Welles
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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11
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Lacombe‐Duncan A, Kattari L, Kattari SK, Scheim AI, Alexander F, Yonce S, Misiolek BA. HIV testing among transgender and nonbinary persons in Michigan, United States: results of a community-based survey. J Int AIDS Soc 2022; 25 Suppl 5:e25972. [PMID: 36225152 PMCID: PMC9557000 DOI: 10.1002/jia2.25972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/19/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Transgender (trans) and nonbinary people (TNB) are disproportionately impacted by HIV. HIV testing is critical to engage TNB people in HIV prevention and care. Yet, scant literature has examined social and structural factors associated with HIV testing among TNB people of diverse genders and in geographies with potentially lower trans acceptance. We: (1) characterized the prevalence of never having been tested for HIV; and (2) identified associated factors, among TNB people in Michigan, United States. METHODS Data were from a community-based participatory cross-sectional survey (n = 539 sexually experienced TNB people). The prevalence of never having had an HIV test was reported overall and compared across socio-demographic, clinical, social and structural factors using bivariable and multivariable logistic regression analyses. RESULTS AND DISCUSSION Approximately one-quarter (26.2%) of participants had never had an HIV test (20.8% transfeminine; 30.0% transmasculine; 17.8% nonbinary assigned male at-birth; and 32.0% nonbinary assigned female at-birth). In a multivariable socio-demographic model, older age (adjusted odds ratio [aOR] for 1-year increase: 0.93, 95% CI: 0.90, 0.96, p<0.001) and Black/African American race (vs. White) (aOR: 0.28, 95% CI: 0.09, 0.86, p<0.05) were associated with increased odds of HIV testing (aORs for never testing). In separate multivariable models controlling for socio-demographics, ever experiencing sexual violence (aOR: 0.38, 95% CI: 0.21, 0.67, p<0.001), not accessed sexual/reproductive healthcare in the past 12 months (aOR: 4.46, 95% CI: 2.68, 7.43, p<0.001) and reporting a very/somewhat inclusive primary care provider (PCP) (aOR: 0.29, 95% CI: 0.17, 0.49, p<0.001) were associated with HIV testing (aORs for never testing). CONCLUSIONS Findings contribute to scant literature about gender-based differences in HIV testing inclusive of transmasculine and nonbinary people. Lack of statistically significant gender differences suggests that broad TNB interventions may be warranted. These could include training healthcare providers in trans-inclusive practices with sexual violence survivors and PCPs in trans-inclusive HIV prevention and care. Findings showing Black participants were less likely to have never had an HIV test suggest the promise of culturally tailored services, though further investigation is needed. Findings identify social and structural factors associated with HIV testing and can inform multi-level interventions to increase TNB person's HIV testing.
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Affiliation(s)
| | - Leonardo Kattari
- School of Social Work, Michigan State UniversityEast LansingMichiganUSA
| | - Shanna K. Kattari
- School of Social Work, University of MichiganAnn ArborMichiganUSA
- Department of Women's and Gender Studies, University of MichiganAnn ArborMichiganUSA
| | - Ayden I. Scheim
- Dornsife School of Public Health, Drexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Flyn Alexander
- School of Social Work, University of MichiganAnn ArborMichiganUSA
| | - Sophie Yonce
- Lyman Briggs College, Michigan State UniversityEast LansingMichiganUSA
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12
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Navarro JM, Scheim AI, Bauer GR. Transgender and non-binary people's preferences for virtual health care post-pandemic: A cross-sectional Canadian study. J Med Internet Res 2022; 24:e40989. [PMID: 36170497 PMCID: PMC9611101 DOI: 10.2196/40989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Virtual health care use has dramatically increased in response to the COVID-19 pandemic, raising the question of its potential role after the pandemic. For transgender (trans) and nonbinary (TNB) people, virtual care is promising because it may expand access to appropriate health care providers. However, emerging research indicates potential disparities in virtual care access related to sociodemographic, health, and social factors. There is a paucity of research on the factors affecting patient preferences for virtual versus in-person care, particularly in TNB communities. Objective This study aimed to identify the sociodemographic, health, and social factors associated with postpandemic virtual care preferences in TNB communities. Methods The 2020 Trans PULSE Canada COVID survey examined the health, social, and economic impacts of the COVID-19 pandemic among 820 TNB participants who previously completed the prepandemic 2019 Trans PULSE Canada survey (n=2783). Data were weighted to the demographics of the 2019 sample. Chi-square tests were used to compare postpandemic preferences for virtual versus in-person care across sociodemographic, health, and social characteristics. Participants provided open-text responses explaining their preferences, which were used to contextualize quantitative findings. Results Among 812 participants who indicated whether they would prefer virtual or in-person care after the pandemic, a weighted 32.7% (n=275) would prefer virtual care and 67.3% (n=537) would prefer in-person care. Preference for in-person over virtual care was associated with being in the 14-19 (49/56, weighted 85.0%), 50-64 (51/62, weighted 80.0%), and ≥65 (9/10, weighted 90.7%) age groups (χ25=19.0; P=.002). Preference for virtual over in-person care was associated with having a chronic health condition (125/317, weighted 37.7% versus 150/495, weighted 29.9%; χ21=4.7; P=.03) and having probable anxiety (229/645, weighted 34.7% versus 46/167, weighted 25.7%; χ21=4.3; P=.04). Among participants with romantic partners, preferences varied based on the partner’s level of support for gender identity or expression (χ23=13.3; P=.004). Participants with moderately supportive partners were more likely than participants with very supportive partners to prefer in-person care (36/43, weighted 85.1% versus 275/445, weighted 62.3%). Care preferences did not vary significantly based on the indicators of socioeconomic status. Open-text responses showed that multiple factors often interacted to influence participant preferences, and that some factors, such as having a chronic condition, simultaneously led some participants to prefer virtual care and others to prefer in-person care. Conclusions TNB people may have differential interest in virtual care based on factors including age, chronic and mental health conditions, and gender-unsupportive home environments. Future research examining virtual care preferences would benefit from mixed methods intersectional approaches across these factors, to explore complexity in the barriers and facilitators of virtual care access and quality. These observed differences support flexibility with options to choose between in-person and virtual health care to meet TNB patients’ specific health needs.
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Affiliation(s)
- Jose M Navarro
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, 3rd Fl.1465 Richmond Street, London, CA
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, 3rd Fl.1465 Richmond Street, London, CA.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, US
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, 3rd Fl.1465 Richmond Street, London, CA
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13
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Restar A, Dusic EJ, Garrison-Desany H, Lett E, Everhart A, Baker KE, Scheim AI, Beckham SW, Reisner S, Rose AJ, Mimiaga MJ, Radix A, Operario D, Hughto JM. Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults. Humanit Soc Sci Commun 2022; 9:304. [PMID: 36636110 PMCID: PMC9833814 DOI: 10.1057/s41599-022-01291-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/25/2022] [Indexed: 06/17/2023]
Abstract
Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.
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Affiliation(s)
- Arjee Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT, USA
- Center for Applied Transgender Studies, Chicago, IL, USA
| | - E. J. Dusic
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Henri Garrison-Desany
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elle Lett
- Center for Applied Transgender Studies, Chicago, IL, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Avery Everhart
- Center for Applied Transgender Studies, Chicago, IL, USA
- Population, Health, & Place Program, Spatial Sciences Institute, Dornsife College of Letters, Arts, & Sciences, University of Southern California, Los Angeles, CA, USA
| | - Kellan E. Baker
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Whitman-Walker Institute, Washington, DC, USA
| | - Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sari Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Adam J. Rose
- Hebrew University School of Public Health, Jerusalem, Israel
| | - Matthew J. Mimiaga
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Asa Radix
- Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT, USA
- Department of Epidemiology, Columbia University, New York, NY, USA
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Don Operario
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Jaclyn M.W. Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Fenway Health, The Fenway Institute, Boston, MA, USA
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14
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 455] [Impact Index Per Article: 227.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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15
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Tran NK, Baker KE, Lett E, Scheim AI. State-level heterogeneity in associations between structural stigma and individual healthcare access: A multilevel analysis of transgender adults in the United States. J Health Serv Res Policy 2022; 28:109-118. [PMID: 36040166 DOI: 10.1177/13558196221123413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability. METHODS Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy. RESULTS An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability. CONCLUSIONS Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.
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Affiliation(s)
- Nguyen K Tran
- Doctoral Fellow, Department of Epidemiology and Biostatistics, 582373Drexel University, USA
| | - Kellan E Baker
- Executive Director, Whitman-Walker Institute, USA.,Associate Faculty Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, USA
| | - Elle Lett
- Senior Fellow, Center for Applied Transgender Studies, USA.,Postdoctoral Fellow, Computational Health Informatics Program, Boston Children's Hospital, USA.,Doctor of Medicine Candidate, Perelman School of Medicine, 6572University of Pennsylvania, USA
| | - Ayden I Scheim
- Assistant Professor, Department of Epidemiology and Biostatistics, 582373Drexel University, USA.,Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Canada
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16
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Kia H, Rutherford L, Jackson R, Grigorovich A, Ricote CL, Scheim AI, Bauer GR. Impacts of COVID-19 on trans and non-binary people in Canada: a qualitative analysis of responses to a national survey. BMC Public Health 2022; 22:1284. [PMID: 35780082 PMCID: PMC9250198 DOI: 10.1186/s12889-022-13684-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 06/15/2022] [Indexed: 11/14/2022] Open
Abstract
Background Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada. Methods Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic’s impacts. Results Our results are organized into five themes that highlight the pandemic’s impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation. Conclusion Our findings highlight the pandemic’s systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention.
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Affiliation(s)
- Hannah Kia
- School of Social Work, The University of British Columbia, 2080 West Mall, Vancouver, BC, V6T 1Z2, Canada.
| | - Leo Rutherford
- School of Public Health and Social Policy, University of Victoria, Room B202, Human and Social Development Building, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Randy Jackson
- School of Social Work, McMaster University, Room 319, Kenneth Taylor Hall, 1280 Main Street West, Hamilton, ON, L8S 4M4, Canada.,Department of Health, Aging and Society, McMaster University, Room 226, Kenneth Taylor Hall, 1280 Main Street West, Hamilton, ON, L8S 4M4, Canada
| | - Alisa Grigorovich
- Recreation and Leisure Studies, Brock University, 1812 Sir Isaac Brock Way, St Catharines, ON, L2S 3A1, Canada
| | - Carol Lopez Ricote
- Department of Epidemiology and Biostatistics, Western University, 3rd Floor, Western Centre for Public Health and Family Medicine, 1465 Richmond Street, London, ON, N6G 2M1, Canada
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Western University, 3rd Floor, Western Centre for Public Health and Family Medicine, 1465 Richmond Street, London, ON, N6G 2M1, Canada.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market Street, Philadelphia, PA, 19104, USA
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Western University, 3rd Floor, Western Centre for Public Health and Family Medicine, 1465 Richmond Street, London, ON, N6G 2M1, Canada
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17
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Chakrapani V, Scheim AI, Newman PA, Shunmugam M, Rawat S, Baruah D, Bhatter A, Nelson R, Jaya A, Kaur M. Affirming and negotiating gender in family and social spaces: Stigma, mental health and resilience among transmasculine people in India. Cult Health Sex 2022; 24:951-967. [PMID: 33847243 PMCID: PMC7612960 DOI: 10.1080/13691058.2021.1901991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 03/08/2021] [Indexed: 06/12/2023]
Abstract
Research on transmasculine people's health is scant globally, including in India. We explored transmasculine people's experiences in affirming their gender in family and social spaces, and how those experiences impact mental health. In 2019, we conducted four focus groups (n = 17 participants) and 10 in-depth interviews with transmasculine people in Mumbai and Chennai. Data analyses were guided by minority stress theory and the gender affirmation model. Within family, the pressure to conform to assigned gender roles and gender policing usually began in adolescence and increased over time. Some participants left parental homes due to violence. In educational settings, participants described the enforcement of gender-normative dress codes, lack of faculty support, and bullying victimisation, which led some to quit schooling. In the workplace, experiences varied depending on whether participants were visibly trans or had an incongruence between their identity documents and gender identity. Everyday discrimination experiences in diverse settings contributed to psychological distress. Amidst these challenges, participants reported resilience strategies, including self-acceptance, connecting with peers, strategic (non)disclosure, and circumventing gendered restrictions on dress and behaviour. Interventions at social-structural, institutional, family and individual levels are needed to reduce stigma and discrimination faced by transmasculine people in India and to promote their mental health.
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Affiliation(s)
- Venkatesan Chakrapani
- Centre for Sexuality and Health Research and Policy (C-SHaRP), Chennai, India
- The Humsafar Trust, Mumbai, India
| | - Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Peter A. Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Murali Shunmugam
- Centre for Sexuality and Health Research and Policy (C-SHaRP), Chennai, India
| | | | | | | | - Ruban Nelson
- Centre for Sexuality and Health Research and Policy (C-SHaRP), Chennai, India
- The Humsafar Trust, Mumbai, India
| | - A Jaya
- Sahodaran, Chennai, India
| | - Manmeet Kaur
- Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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18
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Tami A, Ferguson T, Bauer GR, Scheim AI. Avoidance of primary healthcare among transgender and non-binary people in Canada during the COVID-19 pandemic. Prev Med Rep 2022; 27:101789. [PMID: 35402149 PMCID: PMC8979617 DOI: 10.1016/j.pmedr.2022.101789] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 03/23/2022] [Accepted: 04/02/2022] [Indexed: 12/01/2022] Open
Abstract
Transgender (trans) and non-binary people experience barriers to culturally competent healthcare and many have reported avoiding care. COVID-19 and related mitigation strategies may have exacerbated avoidance, and poor mental health may be bidirectionally related to avoiding care. This study estimated the prevalence of primary care avoidance during the pandemic in a national sample of trans and non-binary people in Canada with a primary care provider and examined the association between poorer self-rated mental health and avoidance. In Fall 2019, Trans PULSE Canada collected multi-mode survey data from trans and non-binary people. In September to October 2020, 820 participants completed a COVID-19-focused survey. In this cross-sectional analysis, multivariable logistic regression models estimated odds ratios adjusted for confounders and weighted to the 2019 sample. The analysis included 689 individuals with a primary healthcare provider, of whom 61.2% (95% CI: 57.2, 65.2) reported fair or poor mental health and 25.7% (95% CI: 22.3, 29.2) reported care avoidance during the pandemic. The most common reason for avoidance was having a non-urgent health concern (72.7%, 95% CI: 65.9, 79.5). In adjusted analyses, those with fair or poor mental health had higher odds of avoiding primary care as compared to those with good to excellent mental health (adjusted odds ratio [AOR] = 2.37; 95% CI: 1.50, 3.77). This relationship was similar when excluding COVID-related reasons for avoidance (AOR = 2.52; 95% CI: 1.52, 4.17). Expansion of virtual communication may enhance primary care accessibility, and proactively assessing mental health symptoms may facilitate connections to gender-affirming mental health services.
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Affiliation(s)
- Abigail Tami
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Greta R. Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Trans PULSE Canada, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
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19
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Earnshaw VA, Jonathon Rendina H, Bauer GR, Bonett S, Bowleg L, Carter J, English D, Friedman MR, Hatzenbuehler ML, Johnson MO, McCree DH, Neilands TB, Quinn KG, Robles G, Scheim AI, Smith JC, Smith LR, Sprague L, Taggart T, Tsai AC, Turan B, Yang LH, Bauermeister JA, Kerrigan DL. Methods in HIV-Related Intersectional Stigma Research: Core Elements and Opportunities. Am J Public Health 2022; 112:S413-S419. [PMID: 35763749 PMCID: PMC9241464 DOI: 10.2105/ajph.2021.306710] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 02/04/2023]
Abstract
Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. (Am J Public Health. 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).
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Affiliation(s)
- Valerie A Earnshaw
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - H Jonathon Rendina
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Greta R Bauer
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Stephen Bonett
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Lisa Bowleg
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Joseph Carter
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Devin English
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - M Reuel Friedman
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Mark L Hatzenbuehler
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Mallory O Johnson
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Donna H McCree
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Torsten B Neilands
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Katherine G Quinn
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Gabriel Robles
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Ayden I Scheim
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Justin C Smith
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Laramie R Smith
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Laurel Sprague
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Tamara Taggart
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Alexander C Tsai
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Bulent Turan
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Lawrence H Yang
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - José A Bauermeister
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
| | - Deanna L Kerrigan
- Valerie A. Earnshaw is with the Department of Human Development and Family Sciences, College of Education and Human Development, University of Delaware, Newark. H. Jonathon Rendina is with the Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC. Greta R. Bauer is with the Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. Stephen Bonett is with the School of Nursing, University of Pennsylvania, Philadelphia. Lisa Bowleg is an AJPH Associate Editor and is with the Department of Psychological and Brain Sciences, George Washington University. Joseph Carter is with the Department of Psychology, Hunter College, New York, NY. Devin English is with the Department of Urban-Global Public Health, School of Public Health, Rutgers University, New Brunswick, NJ. M. Reuel Friedman is with the Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. Mark L. Hatzenbuehler is with the Department of Psychology, Harvard University, Cambridge, MA. Mallory O. Johnson and Torsten B. Neilands are with the Department of Medicine, University of California, San Francisco. Donna H. McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Katherine G. Quinn is with the Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee. Gabriel Robles is with the School of Social Work, Rutgers University, New Brunswick. Ayden I. Scheim is with the Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA. Justin C. Smith is with Positive Impact Health Centers, Atlanta. Laramie R. Smith is with the Division of Global Public Health and Infectious Diseases, School of Medicine, University of California, San Diego. Laurel Sprague is with the Department of Gender Equality, Human Rights, and Community Engagement, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland. Tamara Taggart and Deanna L. Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University. Alexander C. Tsai is with the Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston. Bulent Turan is with the Department of Psychology, Koc University, Istanbul, Turkey. Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. José A. Bauermeister is with the Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia. Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
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Dang M, Scheim AI, Teti M, Quinn KG, Zarwell M, Petroll AE, Horvath KJ, John SA. Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review. AIDS Patient Care STDS 2022; 36:236-248. [PMID: 35687813 PMCID: PMC9242706 DOI: 10.1089/apc.2021.0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.
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Affiliation(s)
- Madeline Dang
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Michelle Teti
- Department of Health Sciences, School of Health Professions, University of Missouri, Columbia, Missouri, USA
| | - Katherine G. Quinn
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Meagan Zarwell
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Andrew E. Petroll
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Keith J. Horvath
- Department of Psychology, San Diego State University, San Diego, California, USA
| | - Steven A. John
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Address correspondence to: Steven A. John, PhD, MPH, Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 2071 N. Summit Avenue, Milwaukee, WI 53202, USA
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21
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Werb D, Scheim AI, Soipe A, Aeby S, Rammohan I, Fischer B, Hadland SE, Marshall BDL. Health harms of non-medical prescription opioid use: A systematic review. Drug Alcohol Rev 2022; 41:941-952. [PMID: 35437841 PMCID: PMC9064965 DOI: 10.1111/dar.13441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 11/30/2022]
Abstract
ISSUES Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken. APPROACH We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality. KEY FINDINGS Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%). IMPLICATIONS A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault. DISCUSSION AND CONCLUSIONS Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.
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Affiliation(s)
- Dan Werb
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Ayorinde Soipe
- Department of Epidemiology, Brown University School of Public Health, Providence, USA.,Division of Nephrology, Department of Medicine, State University of New York, New York, USA
| | - Samantha Aeby
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Indhu Rammohan
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Benedikt Fischer
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, Canada.,Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
| | - Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, USA.,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, USA
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22
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Maghsoudi N, Tanguay J, Scarfone K, Rammohan I, Ziegler C, Werb D, Scheim AI. Drug checking services for people who use drugs: a systematic review. Addiction 2022; 117:532-544. [PMID: 34729849 PMCID: PMC9299873 DOI: 10.1111/add.15734] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services. METHODS Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools. RESULTS We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services. CONCLUSIONS Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use.
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Affiliation(s)
- Nazlee Maghsoudi
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge InstituteSt Michael's HospitalTorontoONCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
| | - Justine Tanguay
- Munk School of Global Affairs and Public PolicyUniversity of TorontoTorontoONCanada
| | - Kristy Scarfone
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge InstituteSt Michael's HospitalTorontoONCanada,Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoONCanada
| | - Indhu Rammohan
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge InstituteSt Michael's HospitalTorontoONCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada
| | | | - Dan Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge InstituteSt Michael's HospitalTorontoONCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoONCanada,Division of Infectious Diseases and Global Public Health, School of MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Ayden I. Scheim
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge InstituteSt Michael's HospitalTorontoONCanada,Department of Epidemiology and Biostatistics, Dornsife School of Public HealthDrexel UniversityPhiladelphiaPAUSA
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23
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Bouck Z, Tricco AC, Rosella LC, Ling V, Gomes T, Tadrous M, Fox MP, Scheim AI, Werb D. Validation of Self-reported Opioid Agonist Treatment Among People Who Inject Drugs Using Prescription Dispensation Records. Epidemiology 2022; 33:287-294. [PMID: 34799473 DOI: 10.1097/ede.0000000000001443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies of people who inject drugs (PWID) commonly use questionnaires to determine whether participants are currently, or have recently been, on opioid agonist treatment for opioid use disorder. However, these previously unvalidated self-reported treatment measures may be susceptible to inaccurate reporting. METHODS We linked baseline questionnaire data from 521 PWID in the Ontario integrated Supervised Injection Services cohort in Toronto (November 2018-March 2020) with record-level health administrative data. We assessed the validity (sensitivity, specificity, positive and negative predictive value [PPV and NPV]) of self-reported recent (in the past 6 months) and current (as of interview) opioid agonist treatment with methadone or buprenorphine-naloxone relative to prescription dispensation records from a provincial narcotics monitoring system, considered the reference standard. RESULTS For self-reported recent opioid agonist treatment, sensitivity was 78% (95% CI = 72, 83), specificity was 90% (95% CI = 86, 94), PPV was 90% (95% CI = 85, 93), and NPV was 79% (95% CI = 74, 84). For self-reported current opioid agonist treatment, sensitivity was 84% (95% CI = 78, 90), specificity was 87% (95% CI = 83, 91), PPV was 74% (95% CI = 67, 81), and NPV was 93% (95% CI = 89, 95). CONCLUSIONS Self-reported opioid agonist treatment measures were fairly accurate among PWID, with some exceptions. Inaccurate recall due to a lengthy lookback window may explain underreporting of recent treatment, whereas social desirability bias may have led to overreporting of current treatment. These validation data could be used in future studies of PWID to adjust for misclassification in similar self-reported treatment measures.
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Affiliation(s)
- Zachary Bouck
- From the Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Andrea C Tricco
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Knowledge Translation Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Laura C Rosella
- From the Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | | | - Tara Gomes
- ICES, Toronto, ON, Canada
- Ontario Drug Policy Research Network, Toronto, ON, Canada
| | - Mina Tadrous
- Ontario Drug Policy Research Network, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Dan Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
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24
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Zlotorzynska M, Sanchez TH, Scheim AI, Lyons CE, Maksut JL, Wiginton JM, Baral SD. Transgender Women's Internet Survey and Testing: Protocol and Key Indicators Report. Transgend Health 2022; 6:256-266. [PMID: 34993298 DOI: 10.1089/trgh.2020.0071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: There is a need for ongoing behavioral surveillance of human immunodeficiency virus (HIV)/sexually transmitted infection (STI) risk among transgender women, using assessments adapted to this population. We therefore developed and piloted the Transgender Women's Internet Survey and Testing (TWIST) study, a cross-sectional behavioral survey of transgender women in the United States coupled with remote biospecimen collection and testing. Methods: Participants age 15+ were recruited by using social media advertisements. Participants were eligible to take the survey if they reported male sex at birth, identified as female or as a transgender woman, resided in the United States, and reported ever having oral, vaginal, or anal sex. We examined a number of behavioral indicators by age, county population density, and medical gender affirmation treatment, using multivariable regression modeling. A sample of respondents was invited to receive a home biospecimen collection kit for HIV/STI testing. Results: The 401 participants were mainly non-Hispanic white and younger than 25 years. Self-reported HIV prevalence was 1.3% (5/401), and almost half (47.1%, 189/401) did not know their HIV status. Receiving medical gender affirmation was strongly associated with past-year HIV and STI testing, independent of general health care engagement. Of the 155 participants invited to receive home biospecimen collection kits, 48 (31.0%) consented and of those, 21 (43.8%) returned specimens for testing. Conclusion: This pilot study successfully reached its recruitment target and generated useful behavioral measures from an online sample of transgender women. We anticipate that online recruitment combined with self-collection of biospecimens will serve as an innovative and scalable strategy for ongoing monitoring of HIV/STI behavioral trends among U.S. transgender women.
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Affiliation(s)
- Maria Zlotorzynska
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Travis H Sanchez
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ayden I Scheim
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Carrie E Lyons
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland , USA
| | - Jessica L Maksut
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland , USA
| | - John Mark Wiginton
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland , USA
| | - Stefan D Baral
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland , USA
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25
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Abstract
Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA; .,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kellan E Baker
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Whitman-Walker Institute, Whitman-Walker Health, Washington, DC, USA
| | - Arjee J Restar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington 98195, USA
| | - Randall L Sell
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
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26
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Lacombe-Duncan A, Logie CH, Persad Y, Leblanc G, Nation K, Kia H, Scheim AI, Lyons T, Horemans C, Olawale R, Loutfy M. Implementation and evaluation of the 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)' provider education pilot. BMC Med Educ 2021; 21:561. [PMID: 34732178 PMCID: PMC8566115 DOI: 10.1186/s12909-021-02991-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/21/2021] [Indexed: 05/14/2023]
Abstract
BACKGROUND Transgender (trans) women face constrained access to gender-affirming HIV prevention and care. This is fueled in part by the convergence of limited trans knowledge and competency with anti-trans and HIV-related stigmas among social and healthcare providers. To advance gender-affirming HIV service delivery we implemented and evaluated 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)'. This theoretically-informed community-developed intervention aimed to increase providers' gender-affirming HIV prevention and care knowledge and competency and reduce negative attitudes and biases among providers towards trans women living with and/or affected by HIV. METHODS Healthcare and social service providers and providers in-training (e.g., physicians, nurses, social workers) working with trans women living with and/or affected by HIV (n = 78) participated in a non-randomized multi-site pilot study evaluating TEACHH with a pre-post-test design. Pre- and post-intervention surveys assessed participant characteristics, intervention feasibility (e.g., workshop completion rate) and acceptability (e.g., willingness to attend another training). Paired sample t-tests were conducted to assess pre-post intervention differences in perceived competency, attitudes/biases, and knowledge to provide gender-affirming HIV care to trans women living with HIV and trans persons. RESULTS The intervention was feasible (100% workshop completion) and acceptable (91.9% indicated interest in future gender-affirming HIV care trainings). Post-intervention scores indicated significant improvement in: 1) knowledge, attitudes/biases and perceived competency in gender-affirming HIV care (score mean difference (MD) 8.49 (95% CI of MD: 6.12-10.86, p < 0.001, possible score range: 16-96), and 2) knowledge, attitudes/biases and perceived competency in gender-affirming healthcare (MD = 3.21; 95% CI of MD: 1.90-4.90, p < 0.001, possible score range: 9-63). Greater change in outcome measures from pre- to post-intervention was experienced by those with fewer trans and transfeminine clients served in the past year, in indirect service roles, and having received less prior training. CONCLUSIONS This brief healthcare and social service provider intervention showed promise in improving gender-affirming provider knowledge, perceived competency, and attitudes/biases, particularly among those with less trans and HIV experience. Scale-up of TEACHH may increase access to gender-affirming health services and HIV prevention and care, increase healthcare access, and reduce HIV disparities among trans women. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04096053 ).
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Affiliation(s)
- Ashley Lacombe-Duncan
- School of Social Work, University of Michigan, 1080 South University Avenue, Ann Arbor, MI, 48109-1106, USA.
- Center for Sexuality and Health Disparities, University of Michigan, 400 North Ingalls Street, Ann Arbor, MI, 48109-5482, USA.
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada.
| | - Carmen H Logie
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, M5S 1V4, Canada
- Center for Gender & Sexual Health Equity (CGSHE), 1190 Hornby Street, Vancouver, V6Z 2K5, Canada
| | - Yasmeen Persad
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
| | - Gabrielle Leblanc
- Action Santé Travesti(e)s & Transsexuel(le)s du Québec (ASTT(E)Q), 1300 Sanguinet, Montréal, H2X 3E7, Canada
| | - Kelendria Nation
- Prism Education Series, Vancouver Coastal Health, 1128 Hornby Street, Vancouver, V6Z 2L4, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, 2080 West Mall, Vancouver, V6T 1Z2, Canada
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA, 19104, USA
| | - Tara Lyons
- Center for Gender & Sexual Health Equity (CGSHE), 1190 Hornby Street, Vancouver, V6Z 2K5, Canada
- Department of Criminology, Kwantlen Polytechnic University, 12666 72 Avenue, Surrey, V3W 2M8, Canada
| | - Chavisa Horemans
- CIHR Canadian HIV Trials Network, 588-1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
| | - Ronke Olawale
- School of Social Work, University of Michigan, 1080 South University Avenue, Ann Arbor, MI, 48109-1106, USA
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S 1A8, Canada
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27
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Abstract
BACKGROUND Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions. METHODS We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data. RESULTS The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider (n = 1803; 81.4%, 95% confidence interval [CI] 79.8%-83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%-84.1%) in the territories to 92.9% (95% CI 83.5%-100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% (n = 1150; 95% CI 50.3%-54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% (n = 978; 95% CI 42.3%-46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment (n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%-32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%-65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study (n = 1046), 40.7% (n = 416; 95% CI 37.8%-43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region (p < 0.05). INTERPRETATION Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics (Scheim), Dornsife School of Public Health, Drexel University, Philadelphia, Pa.; Li Ka Shing Knowledge Institute (Scheim), St. Michael's Hospital, Toronto, Ont.; Department of Health Sciences (Coleman), Wilfrid Laurier University, Waterloo, Ont.; School of Public Health & Social Policy (Lachowsky), Faculty of Human and Social Development, University of Victoria, Victoria, BC; Department of Epidemiology and Biostatistics (Bauer), Schulich School of Medicine & Dentistry, Western University, London, Ont.
| | - Todd Coleman
- Department of Epidemiology and Biostatistics (Scheim), Dornsife School of Public Health, Drexel University, Philadelphia, Pa.; Li Ka Shing Knowledge Institute (Scheim), St. Michael's Hospital, Toronto, Ont.; Department of Health Sciences (Coleman), Wilfrid Laurier University, Waterloo, Ont.; School of Public Health & Social Policy (Lachowsky), Faculty of Human and Social Development, University of Victoria, Victoria, BC; Department of Epidemiology and Biostatistics (Bauer), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Nathan Lachowsky
- Department of Epidemiology and Biostatistics (Scheim), Dornsife School of Public Health, Drexel University, Philadelphia, Pa.; Li Ka Shing Knowledge Institute (Scheim), St. Michael's Hospital, Toronto, Ont.; Department of Health Sciences (Coleman), Wilfrid Laurier University, Waterloo, Ont.; School of Public Health & Social Policy (Lachowsky), Faculty of Human and Social Development, University of Victoria, Victoria, BC; Department of Epidemiology and Biostatistics (Bauer), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics (Scheim), Dornsife School of Public Health, Drexel University, Philadelphia, Pa.; Li Ka Shing Knowledge Institute (Scheim), St. Michael's Hospital, Toronto, Ont.; Department of Health Sciences (Coleman), Wilfrid Laurier University, Waterloo, Ont.; School of Public Health & Social Policy (Lachowsky), Faculty of Human and Social Development, University of Victoria, Victoria, BC; Department of Epidemiology and Biostatistics (Bauer), Schulich School of Medicine & Dentistry, Western University, London, Ont
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28
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Lacombe-Duncan A, Kia H, Logie CH, Todd KP, Persad Y, Leblanc G, Nation K, Scheim AI, Lyons T, Horemans C, Loutfy M. A qualitative exploration of barriers to HIV prevention, treatment and support: Perspectives of transgender women and service providers. Health Soc Care Community 2021; 29:e33-e46. [PMID: 33237600 DOI: 10.1111/hsc.13234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/14/2020] [Accepted: 10/24/2020] [Indexed: 06/11/2023]
Abstract
Transgender (trans) women experience barriers to access to HIV care, which result in their lower engagement in HIV prevention, treatment and support relative to cisgender people living with HIV. Studies of trans women's barriers to HIV care have predominantly focused on perspectives of trans women, while barriers are most often described at provider, organisation and/or systems levels. Comparing perspectives of trans women and service providers may promote a shared vision for achieving health equity. Thus, this qualitative study utilised focus groups and semi-structured interviews conducted 2018-2019 to understand barriers and facilitators to HIV care from the perspectives of trans women (n = 26) and service providers (n = 10). Barriers endorsed by both groups included: (a) anticipated and enacted stigma and discrimination in the provision of direct care, (b) lack of provider knowledge of HIV care needs for trans women, (c) absence of trans-specific services/organisations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of trans-positive trauma-informed care, (b) autonomy and choice for trans women in selecting sexual health services and (c) models for trans-affirming systems change. Each theme had significant overlap, yet nuanced perspective, between trans women and service providers. Specific recommendations to improve HIV care access for trans women are discussed. These recommendations can be used by administrators and service providers alike to work collaboratively with trans women to reduce barriers and facilitators to HIV care and ultimately to achieve health equity for trans women.
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Affiliation(s)
- Ashley Lacombe-Duncan
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, Vancouver, BC, Canada
| | - Carmen H Logie
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Kieran P Todd
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Yasmeen Persad
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Gabrielle Leblanc
- Action Santé Travesti(e)s & Transsexuel(le)s du Québec (ASTT(E)Q), Montréal, Canada
| | - Kelendria Nation
- Prism Education Series, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Tara Lyons
- Department of Criminology, Kwantlen Polytechnic University, Vancouver, BC, Canada
- Center for Gender & Sexual Health Equity (CGSHE), Vancouver, BC, Canada
| | | | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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29
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Scheim AI, Bauer GR, Bastos JL, Poteat T. Advancing Intersectional Discrimination Measures for Health Disparities Research: Protocol for a Bilingual Mixed Methods Measurement Study. JMIR Res Protoc 2021; 10:e30987. [PMID: 34459747 PMCID: PMC8438612 DOI: 10.2196/30987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/05/2021] [Indexed: 01/27/2023] Open
Abstract
Background Guided by intersectionality frameworks, researchers have documented health disparities at the intersection of multiple axes of social status and position, particularly race and ethnicity, gender, and sexual orientation. To advance from identifying to intervening in such intersectional health disparities, studies that examine the underlying mechanisms are required. Although much research demonstrates the negative health impacts of perceived discrimination along single axes, quantitative approaches to assessing the role of discrimination in generating intersectional health disparities remain in their infancy. Members of our team recently introduced the Intersectional Discrimination Index (InDI) to address this gap. The InDI comprises three measures of enacted (day-to-day and major) and anticipated discrimination. These attribution-free measures ask about experiences of mistreatment because of who you are. These measures show promise for intersectional health disparities research but require further validation across intersectional groups and languages. In addition, the proposal to remove attributions is controversial, and no direct comparison has ever been conducted. Objective This study aims to cognitively and psychometrically evaluate the InDI in English and Spanish and determine whether attributions should be included. Methods The study will draw on a preliminary validation data set and three original sequentially collected sources of data: qualitative cognitive interviews in English and Spanish with a sample purposively recruited across intersecting social status and position (gender, sexual orientation, race and ethnicity, socioeconomic status, age, and nativity); a Spanish quantitative survey (n=500; 250/500, 50% sexual and gender minorities); and an English quantitative survey (n=3000), with quota sampling by race and ethnicity (Black, Latino/a/x, and White), sexual or gender minority status, and gender. Results The study was funded by the National Institute on Minority Health and Health Disparities in May 2021, and data collection began in July 2021. Conclusions The key deliverables of the study will be bilingual measures of anticipated, day-to-day, and major discrimination validated for multiple health disparity populations using qualitative, quantitative, and mixed methods. International Registered Report Identifier (IRRID) PRR1-10.2196/30987
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - João L Bastos
- Department of Public Health, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Scheim AI, Sniderman R, Wang R, Bouck Z, McLean E, Mason K, Bardwell G, Mitra S, Greenwald ZR, Thavorn K, Garber G, Baral SD, Rourke SB, Werb D. The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile. J Urban Health 2021; 98:538-550. [PMID: 34181179 PMCID: PMC8237772 DOI: 10.1007/s11524-021-00547-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 11/25/2022]
Abstract
The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33-49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of "safer opioid supply" programs and impacts of COVID-19.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA.,Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada.,Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ruby Sniderman
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Zachary Bouck
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Elizabeth McLean
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, ON, Canada
| | - Geoff Bardwell
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada.,British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada
| | - Sanjana Mitra
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada.,Interdisciplinary Studies Graduate Program, University of British Columbia, 2357 Main Mall, Vancouver, BC, 270, V6T 1Z4, Canada
| | - Zoë R Greenwald
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Gary Garber
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Box, Ottawa, ON, Canada
| | - Stefan D Baral
- Department of Epidemiology, John Hopkins University School of Public Health, Baltimore, MD, USA
| | - Sean B Rourke
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1X1, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, CA, USA.
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Morgan R, Baker P, Griffith DM, Klein SL, Logie CH, Mwiine AA, Scheim AI, Shapiro JR, Smith J, Wenham C, White A. Beyond a Zero-Sum Game: How Does the Impact of COVID-19 Vary by Gender? Front Sociol 2021; 6:650729. [PMID: 34212026 PMCID: PMC8239350 DOI: 10.3389/fsoc.2021.650729] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/24/2021] [Indexed: 06/13/2023]
Abstract
Epidemics and pandemics, like COVID-19, are not gender neutral. Much of the current work on gender, sex, and COVID-19, however, has seemed implicitly or explicitly to be attempting to demonstrate that either men or women have been hardest hit, treating differences between women and men as though it is not important to understand how each group is affected by the virus. This approach often leaves out the effect on gender and sexual minorities entirely. Believing that a more nuanced approach is needed now and for the future, we brought together a group of gender experts to answer the question: how are people of different genders impacted by COVID-19 and why? Individuals working in women's, men's, and LGBTQ health and wellbeing wrote sections to lay out the different ways that women, men, and gender and sexual minorities are affected by COVID-19. We demonstrate that there is not one group "most affected," but that many groups are affected, and we need to move beyond a zero-sum game and engage in ways to mutually identify and support marginalized groups.
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Affiliation(s)
- Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Peter Baker
- Global Action on Men’s Health, London, United Kingdom
| | - Derek M Griffith
- Founder and Director of the Center for Research on Men’s Health and Professor of Medicine, Health and Society, Vanderbilt University, Nashville, TN, United States
| | - Sabra L. Klein
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- W. Harry Feinstone Department of Molecular Microbiology and Immunology and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, Canada and Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Amon Ashaba Mwiine
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States
| | - Janna R. Shapiro
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Julia Smith
- Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Clare Wenham
- Department of Health Policy, London School of Economics and Political Science, Leeds, United Kingdom
| | - Alan White
- Emeritus Professor of Men’s Health, Leeds Beckett University, Leeds, United Kingdom
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Roth AM, Mitchell AK, Mukherjee R, Scheim AI, Ward KM, Lankenau SE. Prevalence and Correlates of Syringe Disposal Box Use in a Philadelphia Neighborhood with High Levels of Public Drug Injection. Subst Use Misuse 2021; 56:668-673. [PMID: 33663334 DOI: 10.1080/10826084.2021.1887252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Philadelphia (Pennsylvania, USA) is facing an unprecedented public health crisis due to fentanyl use. To combat drug-related litter, the Philadelphia Department of Public Health installed 7 public syringe disposal boxes (SDB) in Kensington, the neighborhood most impacted by the opioid crisis and home to a syringe exchange. Methods: We used street- and business-intercepts to recruit residents (N=358) and business owners/staff (N=78) who completed a brief survey with two binary items measuring observing and using SDB. Multivariable logistic regression was used to assess factors independently associated with SDB observance and use. Results: 78% (340/436) observed SDB and 34.1% (116/340) had ever used SDB among those who had seen them. Unstably housed persons had 4.3 times greater odds of observing SDB (Adjusted odds ratio [aOR= 4.29; 95% confidence interval [CI]: 1.56, 11.82) and had 2.5 times greater odds of using SDB (aOR = 2.51; 95% CI: 1.33, 4.74) as did people who use opioids (aOR = 2.61; 95% CI: 1.45, 4.72). Among individuals reporting opioid use who also saw SDB (n=123), those who were unstably housed were more likely to use SDB than those with stable housing (67.8% vs 45.3%, p=.012). Conclusion: These results suggest Kensington residents, especially those who are unstably housed, use SDB once they see them in the neighborhood.
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Affiliation(s)
- Alexis M Roth
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Allison K Mitchell
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Rohit Mukherjee
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Kathleen M Ward
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Stephen E Lankenau
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
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Rich AJ, Scheim AI, Koehoorn M, Poteat T. Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis. Prev Med Rep 2020; 20:101259. [PMID: 33335828 PMCID: PMC7732872 DOI: 10.1016/j.pmedr.2020.101259] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 01/10/2023] Open
Abstract
Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.
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Affiliation(s)
- Ashleigh J. Rich
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
- Corresponding author.
| | - Ayden I. Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States
| | - Mieke Koehoorn
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States
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Scheim AI, Bouck Z, Tookey P, Hopkins S, Sniderman R, McLean E, Garber G, Baral S, Rourke SB, Werb D. Supervised consumption service use and recent non-fatal overdose among people who inject drugs in Toronto, Canada. Int J Drug Policy 2020; 87:102993. [PMID: 33160158 DOI: 10.1016/j.drugpo.2020.102993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/21/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Aiming to reducing overdose mortality, over 40 supervised drug consumption services (SCS) presently operate in Canada. Arguments against SCS include the potential for increased non-fatal overdoses mediated by risk compensation. This study estimates associations between SCS use and recent non-fatal overdose among people who inject drugs (PWID). METHODS We analyzed cross-sectional baseline data collected between November 2018 and March 2020 from a cohort of adult PWID in Toronto, Canada. Recent non-fatal overdose was self-reported over the previous six months. The primary exposure was frequency of SCS use, self-reported as the proportion of injections performed at an SCS (all or most [75-100%], some [26-74%], few [≤25%], or none) in the previous six months. The prevalence of recent overdose was compared between all unique pairs of groups based on their frequency of SCS use and expressed as covariate-adjusted prevalence ratios (PR) estimated using modified Poisson regression. RESULTS Among 701 PWID (median [IQR] age, 40 [33 to 49]; 64.3% cisgender men; 56.8% injecting daily), most reported SCS use (all/most, 26.2%; some, 30.9%; few, 29.4%) versus no use (13.5%), with 38.6% reporting a recent overdose. From adjusted regression analyses, more frequent SCS use was not statistically significantly associated with overdose when compared to either no SCS use or less frequent use. Associations between SCS use frequency and overdose were notably smaller among SCS clients compared to associations between SCS clients and non-users (e.g., all/most versus none: PR, 1.43 [95% CI, 0.93 to 2.21]; all/most versus some: PR, 0.94 [95% CI, 0.75 to 1.17]; all/most versus few: PR, 1.15 [95% CI, 0.89 to 1.48]). CONCLUSION Findings did not indicate statistically significant associations between SCS use frequency and recent non-fatal overdose, particularly among SCS clients who may be more comparable. Nevertheless, overdose was common, underscoring the need to prevent non-fatal overdose and associated morbidity.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States; Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
| | - Zachary Bouck
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Paula Tookey
- South Riverdale Community Health Centre, Toronto, ON, Canada
| | | | - Ruby Sniderman
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Elizabeth McLean
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD, United States
| | - Sean B Rourke
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, CA, United States
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Gicquelais RE, Werb D, Marks C, Ziegler C, Mehta SH, Genberg BL, Scheim AI. Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use. Epidemiol Rev 2020; 42:4-18. [PMID: 33024995 DOI: 10.1093/epirev/mxaa008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 01/13/2023] Open
Abstract
Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.
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Ferlatte O, Panwala V, Rich AJ, Scheim AI, Blackwell E, Scott K, Salway T, Knight R. Identifying Health Differences Between Transgender and Cisgender Gay, Bisexual and Other Men Who Have Sex With Men Using a Community-Based Approach. J Sex Res 2020; 57:1005-1013. [PMID: 32186417 DOI: 10.1080/00224499.2020.1740148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In this article, we describe a community-based research (CBR) approach to making a national online survey of gay, bisexual, and other men who have sex with men (GBMSM) inclusive of transgender GBMSM by working with members of the transgender community at all stages of the research process. This collaboration resulted in 209 transgender GBMSM completing our survey and we contrasted their health experiences with 7439 cisgender GBMSM. We found that transgender GBMSM were less likely than cisgender GBMSM to report intercourse without a condom (AOR 0.43; 95% CI: 0.28-0.66) and to have had an HIV test (AOR 0.64; 95% CI 0.49-0.85). Transgender GBMSM were more likely to report discrimination in the health care system in their lifetime (AOR 4.17; 95% CI 3.03-5.73), to self-rate their health as poor (AOR 3.47; 95% CI 2.52-4.80), and to have discussed depression (AOR 3.47; 95% CI 262-4.59) or anxiety (AOR 3.27; 95% CI 2.47-4.33) with a health care provider. Our experience highlights the feasibility of including transgender individuals in GBMSM research, while the results affirm the need for GBMSM health services to take into account the unique experiences of transgender GBMSM.
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Affiliation(s)
- Olivier Ferlatte
- Department of Social and Preventative Medicine, School of Public Health, University of Montreal
- Centre de Recherche en Santé Publique
- Community-Based Research Centre
| | | | - Ashleigh J Rich
- School of Population and Public Health, University of British Columbia
| | - Ayden I Scheim
- Department of Medicine, University of California San Diego
- Department of Epidemiology and Biostatistics, Drexel University
| | | | | | - Travis Salway
- Community-Based Research Centre
- Faculty of Health Sciences, Simon Fraser University
- British Columbia Centre for Disease Control
- Centre for Gender and Sexual Health Equity
| | - Rod Knight
- Community-Based Research Centre
- British Columbia Centre on Substance Use
- Department of Medicine, University of British Columbia
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Scheim AI, Maghsoudi N, Marshall Z, Churchill S, Ziegler C, Werb D. Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review. BMJ Open 2020; 10:e035148. [PMID: 32958480 PMCID: PMC7507857 DOI: 10.1136/bmjopen-2019-035148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally. DESIGN Systematic review with narrative synthesis. DATA SOURCES We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018. INCLUSION CRITERIA Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest. RESULTS We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use. CONCLUSIONS Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.
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Affiliation(s)
- Ayden I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
| | - Nazlee Maghsoudi
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zack Marshall
- Social Work, McGill University, Montreal, Quebec, Canada
| | - Siobhan Churchill
- Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Carolyn Ziegler
- Library Services, Unity Health Toronto, Toronto, Ontario, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
- Medicine, University of California San Diego, La Jolla, California, USA
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Lacombe-Duncan A, Logie CH, Persad Y, Leblanc G, Nation K, Kia H, Scheim AI, Lyons T, Loutfy M. 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)': protocol of community-based intervention development and a non-randomised multisite pilot study with pre-post test design in Canada. BMJ Open 2020; 10:e034144. [PMID: 32737085 PMCID: PMC7398088 DOI: 10.1136/bmjopen-2019-034144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Educational workshops are a promising strategy to increase healthcare providers' ability to provide gender-affirming care for transgender (trans) people. This strategy may also reduce healthcare providers' stigma towards trans people and people living with HIV. There is less evidence, however, of educational workshops that address HIV prevention and care among trans women. This protocol details development and pilot testing of the Transgender Education for Affirmative and Competent HIV and Healthcare intervention that aims to increase gender-affirming HIV care knowledge and perceived competency, and to reduce negative attitudes/biases, among providers. METHODS AND ANALYSIS This community-based research (CBR) project involves intervention development and implementation of a non-randomised multisite pilot study with pre-post test design. First, we conducted a qualitative formative phase involving focus groups with 30 trans women and individual interviews with 12 providers to understand HIV care access barriers for trans women and elicit feedback on a proposed workshop. Second, we will pilot test the intervention with 90-150 providers (n=30-50×3 in-person settings). For pilot studies, primary outcomes include feasibility (eg, completion rate) and acceptability (eg, workshop satisfaction). Secondary preintervention and postintervention outcomes, assessed directly preceding and following the workshop, include perceived competency, attitudes/biases towards trans women with HIV, and knowledge needed to provide gender-affirming HIV care. Primary outcomes will be summarised as frequencies and proportions (categorical variables). We will conduct paired-sample t-tests to explore the direction of preintervention and postintervention differences for secondary outcomes. ETHICS AND DISSEMINATION This study has been approved by the University of Toronto HIV Research Ethics Board (Protocol Number: 00036238). Study findings will be disseminated through community forums with trans women and service providers; manuscripts submitted to peer reviewed journals; and conferences. Findings will inform a larger CBR research agenda to remove barriers to engagement in HIV prevention/care among trans women across Canada. TRIAL REGISTRATION NUMBER NCT04096053; Pre-results.
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Affiliation(s)
- Ashley Lacombe-Duncan
- School of Social Work, University of Michigan, Ann Arbor, Michigan, USA
- Women's College Hospital, Toronto, Ontario, Canada
| | - Carmen H Logie
- Women's College Hospital, Toronto, Ontario, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Gabrielle Leblanc
- Action Santé Travesti(e)s & Transsexuel(le)s du Québec, Montreal, Québec, Canada
| | - Kelendria Nation
- Prism Education Series, Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Hannah Kia
- School of Social Work, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Tara Lyons
- Department of Criminology, Kwantlen Polytechnic University, Surrey, British Columbia, Canada
- Center for Gender & Sexual Health Equity (CGSHE), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mona Loutfy
- Women's College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Scheim AI, Perez-Brumer AG, Bauer GR. Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study. Lancet Public Health 2020; 5:e196-e203. [PMID: 32192577 PMCID: PMC9912749 DOI: 10.1016/s2468-2667(20)30032-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transgender (trans) people experience profound mental health disparities compared with the general population, attributable in part to the psychological effects of gender non-affirmation. Despite the barriers to legal gender affirmation for trans people, little is known about its association with mental health. We therefore sought to determine whether having gender-concordant identity documents (IDs) is associated with mental health among trans adults in the USA. We hypothesised that having an ID that reflects one's preferred name and gender marker would be associated with reduced psychological distress and suicide risk. METHODS In this cross-sectional observational study, we obtained data from the 2015 US Transgender Survey, the largest cross-sectional survey of trans adults in the USA, with 27 715 participants. Eligible participants were adults (≥18 years), residing in a US state, territory, or overseas US military base; and considered themselves transgender, trans, genderqueer, non-binary, or similar. We excluded participants not living day-to-day in a different gender to the sex they were assigned at birth, participants who identified as crossdressers, and those missing data. The primary exposure of interest was whether all or some (vs none) of a respondent's IDs reflected their preferred name and gender marker. We examined associations with psychological distress (measured with the Kessler 6 scale) and suicide ideation, planning, and attempts in the past year, which we analysed using linear and modified Poisson regression models to examine associations with respondents' IDs. FINDINGS Of 22 286 respondents included in our analytic sample, 10 288 (weighted percentage 45·1%) had their preferred name and gender marker on none, 9666 (44·2%) on some, and 2332 (10·7%) on all of their IDs. Compared with those with no gender-concordant ID, respondents for whom all IDs were concordant had lower prevalence of serious psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61-0·76), suicidal ideation (0·78, 0·72-0·85), and suicide planning (0·75, 0·64-0·87), adjusting for potential confounders. Having some versus no concordant ID was generally associated with smaller reductions in distress and suicidality. Gender-concordant ID was not associated with suicide attempts (eg, adjusted prevalence ratio for all vs no IDs was 0·92, 95% CI 0·68-1·24). INTERPRETATION Possession of gender-concordant IDs might improve mental health among trans persons. Gender recognition policies should be considered structural determinants of transgender health. FUNDING None.
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Affiliation(s)
- Ayden I Scheim
- Department of Medicine, University of California San Diego, La Jolla, CA, USA; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA.
| | - Amaya G Perez-Brumer
- Division of Social and Behavioural Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Maghsoudi N, McDonald K, Stefan C, Beriault DR, Mason K, Barnaby L, Altenberg J, MacDonald RD, Caldwell J, Nisenbaum R, Leece P, Watson TM, Tupper KW, Kufner L, Scheim AI, Werb D. Evaluating networked drug checking services in Toronto, Ontario: study protocol and rationale. Harm Reduct J 2020; 17:9. [PMID: 32204713 PMCID: PMC7092475 DOI: 10.1186/s12954-019-0336-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/06/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The increasing incidence of fatal opioid overdose is a public health crisis in Canada. Given growing consensus that this crisis is related to the presence of highly potent opioid adulterants (e.g., fentanyl) in the unregulated drug supply, drug checking services (DCS) have emerged as part of a comprehensive approach to overdose prevention. In Canada's largest city, Toronto, a network of DCS launched in 2019 to prevent overdose and overdose-related risk behaviors. This network employs mass spectrometry technologies, with intake sites co-located with supervised consumption services (SCS) at three frontline harm reduction agencies. The protocol and rationale for assessing the impact of this multi-site DCS network in Toronto is described herein. The aims of this study are to (1) evaluate the impact of DCS access on changes in and factors influencing overdose and related risk behaviors, (2) investigate the perceived capacity of DCS to prevent overdose, and (3) identify composition (qualitative and quantitative) trends in Toronto's unregulated drug supply. METHODS We will use a parallel-mixed-methods design with complementary data sources (including data from chemical analysis of drug samples, quantitative intake and post-test surveys, SCS, coroners, paramedic services, and qualitative interviews), followed by a meta-inference process wherein results from analyses are synthesized. RESULTS Whereas most DCS globally target "recreational drug users," in Toronto, this networked DCS will primarily target marginalized people who use drugs accessing frontline services, many of whom use drugs regularly and by injection. This evolution in the application of DCS poses important questions that have not yet been explored, including optimal service delivery models and technologies, as well as unique barriers for this population. Increasing information on the unregulated drug supply may modify the risk environment for this population of people who use drugs. CONCLUSIONS This study addresses evidence gaps on the emerging continuum of overdose prevention responses and will generate critical evidence on a novel approach to reducing the ongoing high incidence of drug-related morbidity and mortality in Canada and elsewhere.
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Affiliation(s)
- N Maghsoudi
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street Toronto, Ontario, M5B 1 W8, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - K McDonald
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street Toronto, Ontario, M5B 1 W8, Canada
| | - C Stefan
- Clinical Laboratory and Diagnostic Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - D R Beriault
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - K Mason
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - L Barnaby
- Parkdale Queen West Community Health Centre, Toronto, Ontario, Canada
| | - J Altenberg
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - R D MacDonald
- Toronto Paramedic Services, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Caldwell
- Toronto Public Health, Toronto, Ontario, Canada
| | - R Nisenbaum
- MAP Centre for Urban Health Solutions and Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - P Leece
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - T M Watson
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - K W Tupper
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - L Kufner
- Parkdale Queen West Community Health Centre, Toronto, Ontario, Canada
| | - A I Scheim
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street Toronto, Ontario, M5B 1 W8, Canada
- Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - D Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street Toronto, Ontario, M5B 1 W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
- Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, CA, USA.
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Scheim AI, Appenroth MN, Beckham SW, Goldstein Z, Grinspan MC, Keatley JG, Radix A. Transgender HIV research: nothing about us without us. Lancet HIV 2019; 6:e566-e567. [PMID: 31439535 DOI: 10.1016/s2352-3018(19)30269-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Ayden I Scheim
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA.
| | | | - S Wilson Beckham
- Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Zil Goldstein
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Mauro Cabral Grinspan
- Catedra Libre de Estudios Trans, Universidad de Buenos Aires/GATE, Buenos Aires, Argentina
| | - JoAnne G Keatley
- Center of Excellence for Transgender Health, University of California San Francisco, San Francisco, CA, USA; Innovative Response Globally for Trans Women and HIV, Oakland, CA, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, NY, USA
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Dharma C, Scheim AI, Bauer GR. Exploratory Factor Analysis of Two Sexual Health Scales for Transgender People: Trans-Specific Condom/Barrier Negotiation Self-Efficacy (T-Barrier) and Trans-Specific Sexual Body Image Worries (T-Worries). Arch Sex Behav 2019; 48:1563-1572. [PMID: 31172396 DOI: 10.1007/s10508-018-1383-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 05/28/2023]
Abstract
Few sexual health measures have been validated for transgender (trans) populations. Condom/barrier self-efficacy and sexual body image worries are interrelated constructs that may contribute to enhanced and poor sexual health, respectively. We report on the development and initial validation of trans-specific scales designed to measure these constructs. Trans people in Ontario, Canada, who had ever had sex completed these scales as a part of a larger Trans PULSE survey (n = 323). Using exploratory factor analysis, a one-factor solution fit the 8-item Condom/Barrier Negotiation Self-Efficacy Scale (T-Barrier). Two factors were identified for the 7-item Sexual Body Image Worries Scale (T-Worries): "general body image worries" and "trans-related image worries," while two items were recommended for deletion. The scales demonstrated convergent validity with measures such as self-esteem, sexual anxiety, sexual satisfaction, sexual fear, and experiences of transphobia. Further evaluation to confirm these structures within an independent trans sample would be valuable. We recommend the use of these scales for studies of sexual health within trans populations, to enhance our ability to better understand and promote sexual health within trans communities.
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Affiliation(s)
- Christoffer Dharma
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Ayden I Scheim
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON, N6A 5C1, Canada.
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Bauer GR, Scheim AI. Advancing quantitative intersectionality research methods: Intracategorical and intercategorical approaches to shared and differential constructs. Soc Sci Med 2019; 226:260-262. [PMID: 30914246 DOI: 10.1016/j.socscimed.2019.03.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/10/2019] [Indexed: 01/16/2023]
Abstract
A range of methods have recently been proposed for incorporating intersectionality theoretical frameworks into quantitative research methodology. We published a pair of articles on methods for intercategorical intersectionality, in which we distinguished analytic from descriptive studies, identified causal mediation decomposition methods as an appropriate strategy for analytic intercategorical intersectionality, and introduced and validated a group of three new measures of major, day-to-day, and anticipated discrimination for use in intercategorical analysis (Bauer and Scheim, 2019; Scheim and Bauer, 2019). We respond to points raised in four invited commentaries on our original pair of articles-by Evans (2019); Jackson and VanderWeele (2019); Harnois and Bastos (2019); and Richman and Zucker (2019). We discuss differential constructs, which represent those that exist only for those at particular intersections, or for which meanings vary across intersections. Whereas such constructs may be studied intracategorically, in intercategorical studies they place limits on both the types of measures that may be used and the statistical analyses that can be conducted. Most quantitative intersectionality methods work has therefore focused on intracategorical measures, but intercategorical analyses. We present a preliminary agenda for continued methods development in quantitative intersectionality methods.
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Affiliation(s)
- Greta R Bauer
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada; Women's Studies and Feminist Research, Western University, London, Canada.
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada; Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, San Diego, USA
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Leonardi M, Frecker H, Scheim AI, Kives S. Reproductive Health Considerations in Sexual and/or Gender Minority Adolescents. J Pediatr Adolesc Gynecol 2019; 32:15-20. [PMID: 30317009 DOI: 10.1016/j.jpag.2018.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/22/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023]
Abstract
Disparities exist in the area of reproductive health for lesbian, gay, bisexual (LGB), and transgender and gender nonconforming (TGNC) adolescents compared with cisgender, heterosexual adolescents, particularly related to pregnancy and pregnancy risk factors. Review of the literature indicates an estimated increased risk of adolescent pregnancy involvement between 2 and 10 times higher for LGB youth compared with heterosexual youth. This might be explained by a broad spectrum of sexual health risks experienced, including an earlier age of sexual debut, exposure to sexual abuse, and a higher number of sexual partners. TGNC youth face conflict with their gender identity and potentially their sexual orientation. It is likely that their experience is similar to cisgender LGB adolescents as it pertains to reproductive health considerations. TGNC adolescents additionally confront the added challenge of fertility preservation. Health care providers play an important role in identifying and addressing these risk factors to improve the health of LGB and TGNC adolescents. Unfortunately, whether implicit or explicit, bias among health care providers exists and affects patient care. We believe it is the responsibility of health care providers to be informed about the increased needs of these patients and to provide appropriate risk-reducing management while using inclusive and sensitive history-taking and language.
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Affiliation(s)
- Mathew Leonardi
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopic Surgery Unit, Nepean Hospital, University of Sydney, Sydney, Australia; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.
| | - Helena Frecker
- Department of Obstetrics and Gynaecology, Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ayden I Scheim
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California
| | - Sari Kives
- Department of Obstetrics and Gynaecology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
Sexual health research with transfeminine persons (individuals assigned male at birth who identify as female or feminine) has focused on HIV infection and sexual function following medical treatments. Yet, approximately half of transfeminine persons in Ontario, Canada, reported no partnered sex in the previous year. Therefore, we identified sociodemographic, social, and psychosocial factors associated with past-year sexual inactivity among transfeminine Ontarians. A multi-mode respondent-driven sampling survey of transgender people was conducted in 2009-2010 (N = 433), including 173 transfeminine individuals who had ever been sexually active. Frequencies and regression models were weighted using RDS II methods; prevalence ratios were estimated from logistic regression models using average marginal predictions. Of sexually experienced transfeminine persons, 43% (95% CI [31, 55]) reported no past-year sex partners. Sexual inactivity was independently associated with older age, childhood sexual abuse, and residing outside of the province's largest city. Transfeminine persons who had genital surgery for gender affirmation were less likely to be abstinent, as compared to those who were living in their felt gender without surgery. Transphobic harassment and higher levels of trans-related sexual body image worries were also associated with sexual inactivity, as was reduced sexual satisfaction. Implications for research and clinical practice are discussed.
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Affiliation(s)
- Ayden I Scheim
- a Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry , The University of Western Ontario
| | - Greta R Bauer
- a Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry , The University of Western Ontario
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Scheim AI, Bauer GR. The Intersectional Discrimination Index: Development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis. Soc Sci Med 2019; 226:225-235. [PMID: 30674436 DOI: 10.1016/j.socscimed.2018.12.016] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Although intersectional approaches have gained traction in population health research, quantitative discrimination and health studies have tended to focus on a single axis of discrimination (e.g., racism, homophobia). As few discrimination measures function across multiple social identities or positions, we developed the Intersectional Discrimination Index (InDI) for intercategorical intersectionality research, including measures of Anticipated (InDI-A), Day-to-Day (InDI-D), and Major (InDI-M) discrimination that do not require attribution to particular grounds. METHODS We conducted a validity and reliability study with 2016 online survey panel data from Canada and the United States (n = 2583). Internal consistency and dimensionality of the InDI-A were evaluated with exploratory and confirmatory factor analyses. Construct validation included known-groups comparisons, associations with psychological distress, and convergence with existing discrimination measures. Test-retest reliability was examined in a subgroup (n = 150). RESULTS We found support for use of the InDI-A as a unidimensional scale. As hypothesized, racial and sexual/gender minorities reported higher frequencies of all discrimination types (all p < 0.001), and discrimination varied across intersectional categories. Each InDI component was significantly positively associated with psychological distress after controlling for potential confounders. Frequency scores were strongly positively correlated with existing scales. Intraclass correlation coefficients for test-retest reliability of anticipated, lifetime day-to-day, and lifetime major discrimination ranged from 0.70 to 0.72. CONCLUSIONS Final InDI measures include the 9-item InDI-A, 9-item InDI-D, and 13-item InDI-M, for which we have found initial evidence of construct validity and reliability. In combination with sociodemographic information, the InDI measures can be used to evaluate the role of discrimination as a mediator of intersectional health inequalities, and to monitor the prevalence and impacts of discrimination in heterogeneous populations.
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Affiliation(s)
- Ayden I Scheim
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA.
| | - Greta R Bauer
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada; Women's Studies and Feminist Research, Western University, London, Canada
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Abstract
Few data on HIV incidence among men who have sex with men and inject drugs (MSM-PWID) are available. Drawing on a prospective cohort in Vancouver, Canada, we examined the relationship between MSM status and HIV incidence among PWID using Kaplan-Meier analyses and extended Cox regression. Data were collected from 1996 to 2014 and analyzed in 2017. Of 1131 HIV-negative male PWID, 8.6% (n = 97) reported sex with men over the study period. MSM status was crudely associated with HIV incidence [Hazard Ratio (HR) = 1.81; 95% CI 1.08-3.03], but not after adjustment for daily cocaine injection and syringe borrowing (Adjusted HR = 1.33; 95% CI 0.78-2.28). Findings highlight the need for harm reduction interventions and socio-behavioral research focused on MSM-PWID.
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Affiliation(s)
- Ayden I Scheim
- Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, San Diego, CA, 92093, USA.
| | | | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Scheim AI, Bardwell G, Rachlis B, Mitra S, Kerr T. Syringe sharing among people who inject drugs in London, Canada. Can J Public Health 2018; 109:174-182. [PMID: 29981046 DOI: 10.17269/s41997-018-0058-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/20/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID. METHODS Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses. RESULTS Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26). CONCLUSION We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada.,Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Beth Rachlis
- Ontario HIV Treatment Network, 1300 Yonge Street, Suite 600, Toronto, ON, M4T 1X3, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street West, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Sanjana Mitra
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.,Interdisciplinary Studies, University of British Columbia, 270-2357 Main Mall, Vancouver, British Columbia, V6T 1Z4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Scheim AI, Bauer GR, Shokoohi M. Drug use among transgender people in Ontario, Canada: Disparities and associations with social exclusion. Addict Behav 2017; 72:151-158. [PMID: 28411424 DOI: 10.1016/j.addbeh.2017.03.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/16/2017] [Accepted: 03/29/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION We identified the prevalence and correlates of past-year illicit drug use among transgender people in Ontario, Canada, and disparities with the age-standardized non-transgender population. METHODS Data on transgender persons aged 16+ (n=406) were obtained from Trans PULSE, a respondent-driven sampling (RDS) survey (2009-2010). Overall and sex-specific estimates of past-year drug use (cocaine and amphetamines, based on data availability) in the reference population were obtained from Ontario residents aged 16+ (n=39, 980) in the Canadian Community Health Survey (2009-2010), and standardized to the overall and gender-specific transgender age distributions. For regression analyses with Trans PULSE data, past-year drug use included drug types associated with high risk of physical, psychological, and social harm to the user, and RDS-II weights were applied to frequencies and prevalence ratios (PR) derived from blockwise logistic regression models. RESULTS An estimated 12.3% (95% CI: 7.7, 17.0) of transgender Ontarians had used at least one of the specified drugs in the past year, with no significant difference by gender identity. Transgender Ontarians were more likely to use both cocaine (standardized prevalence difference; SPD=6.8%; 95% CI=1.6, 10.9) and amphetamines (SPD=SPD=1.3%, 95% CI=0.2, 3.1) as compared to the age-standardized non-transgender population. History of transphobic assault, homelessness or underhousing, and sex work were associated with greater drug use among transgender persons. CONCLUSIONS The prevalence of cocaine and amphetamine use among transgender people in Ontario, Canada was higher than in the age-standardized reference population. Social exclusion predicted within-group variation in drug use among transgender persons.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, K201 Kresge Building, London, ON N6A 5C1, Canada.
| | - Greta R Bauer
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, K201 Kresge Building, London, ON N6A 5C1, Canada
| | - Mostafa Shokoohi
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, K201 Kresge Building, London, ON N6A 5C1, Canada
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Bauer GR, Braimoh J, Scheim AI, Dharma C. Transgender-inclusive measures of sex/gender for population surveys: Mixed-methods evaluation and recommendations. PLoS One 2017; 12:e0178043. [PMID: 28542498 PMCID: PMC5444783 DOI: 10.1371/journal.pone.0178043] [Citation(s) in RCA: 183] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 05/08/2017] [Indexed: 11/21/2022] Open
Abstract
Given that an estimated 0.6% of the U.S. population is transgender (trans) and that large health disparities for this population have been documented, government and research organizations are increasingly expanding measures of sex/gender to be trans inclusive. Options suggested for trans community surveys, such as expansive check-all-that-apply gender identity lists and write-in options that offer maximum flexibility, are generally not appropriate for broad population surveys. These require limited questions and a small number of categories for analysis. Limited evaluation has been undertaken of trans-inclusive population survey measures for sex/gender, including those currently in use. Using an internet survey and follow-up of 311 participants, and cognitive interviews from a maximum-diversity sub-sample (n = 79), we conducted a mixed-methods evaluation of two existing measures: a two-step question developed in the United States and a multidimensional measure developed in Canada. We found very low levels of item missingness, and no indicators of confusion on the part of cisgender (non-trans) participants for both measures. However, a majority of interview participants indicated problems with each question item set. Agreement between the two measures in assessment of gender identity was very high (K = 0.9081), but gender identity was a poor proxy for other dimensions of sex or gender among trans participants. Issues to inform measure development or adaptation that emerged from analysis included dimensions of sex/gender measured, whether non-binary identities were trans, Indigenous and cultural identities, proxy reporting, temporality concerns, and the inability of a single item to provide a valid measure of sex/gender. Based on this evaluation, we recommend that population surveys meant for multi-purpose analysis consider a new Multidimensional Sex/Gender Measure for testing that includes three simple items (one asked only of a small sub-group) to assess gender identity and lived gender, with optional additions. We provide considerations for adaptation of this measure to different contexts.
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Affiliation(s)
- Greta R. Bauer
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jessica Braimoh
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Ayden I. Scheim
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Christoffer Dharma
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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