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Geffen SR, Poteat T, Dean LT, Malone J, Greene N, Adams MA. Engaging Black sexual minority women in breast cancer research: Lessons in community partnerships. Cancer 2023; 129:3439-3447. [PMID: 37489804 PMCID: PMC10592156 DOI: 10.1002/cncr.34960] [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: 01/19/2023] [Revised: 05/20/2023] [Accepted: 05/25/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Black sexual minority women (BSMW) face significant breast cancer health inequities and are underrepresented in health research because of historical and present-day exclusion. However, there exists no peer-reviewed literature on best practices for the inclusion of BSMW in cancer research. "Our Breast Health: The Access Project" was a national primary data collection study in June 2018 through October 2019 that aimed to identify facilitators and barriers to breast cancer care among BSMW, and that successfully recruited the highest number of BSMW for any national breast cancer screening study at the time of its publication. METHODS The present analysis highlights best practices for reaching BSMW by examining by how effective various recruitment sources were at recruiting BSMW. Recruitment partners were grouped into several categories: (1) cancer focused, (2) Black women or sexual minority women focused, (3) BSMW focused, (4) social media, and (5) other. Then logistic regression was used to estimate the odds that a particular recruitment source category could recruit BSMW compared with other categories. RESULTS Partnerships with community-based organizations led by and intended for BSMW were the most successful at recruiting BSMW, demonstrating the importance of an intersectional approach to recruitment. Community-based organizations focused on BSMW specifically were 26 times more successful in recruiting BSMW to the study compared with recruiting Black women who were not sexual minorities (odds ratio, 26.43 [95% CI, 7.50-93.10]). CONCLUSIONS Successful recruitment enables breast cancer research grounded in the perspectives of BSMW, which can generate key findings that have the potential to remedy longstanding health inequities for this population.
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Affiliation(s)
- Sophia R Geffen
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- CHOP, Philadelphia, Pennsylvania, USA
| | - Tonia Poteat
- University of North Carolina at Chapel Hill School of Medicine, Department of Social Medicine, Chapel Hill, North Carolina, USA
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, USA
| | - Lorraine T Dean
- Johns Hopkins University Bloomberg School of Public Health, Epidemiology, Baltimore, Maryland, USA
| | - Jowanna Malone
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, USA
| | - Naomi Greene
- Johns Hopkins University Bloomberg School of Public Health, Health, Behavior and Society, Baltimore, Maryland, USA
| | - Mary Anne Adams
- ZAMI NOBLA: National Organization of Black Lesbians on Aging, Atlanta, Georgia, USA
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2
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Geffen SR, Wang T, Cahill S, Fontenot HB, Conron K, Wilson JM, Avripas SA, Michaels S, Johns MM, Dunville R. Recruiting, Facilitating, and Retaining a Youth Community Advisory Board to Inform an HIV Prevention Research Project with Sexual and Gender Minority Youth. LGBT Health 2023; 10:93-98. [PMID: 36637887 DOI: 10.1089/lgbt.2022.0213] [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] [Indexed: 01/14/2023] Open
Abstract
Sexual and gender minority (SGM) youth are at disproportionate risk of acquiring HIV, and as such, SGM youth should be meaningfully engaged in research aimed at developing effective, tailored HIV interventions. Youth Community Advisory Boards (YCABs) are an important element of community-engaged research and support the development of community-informed interventions. This article describes recruitment, facilitation, and retention of a YCAB composed of SGM youth in Greater Boston, to inform a national HIV prevention research project. These lessons can serve as a guide to future researchers who want to form YCABs as part of community-engaged research.
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Affiliation(s)
- Sophia R Geffen
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Timothy Wang
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Sean Cahill
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.,Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Kerith Conron
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.,The Williams Institute, UCLA School of Law, Los Angeles, California, USA
| | | | | | | | - Michelle M Johns
- Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard Dunville
- Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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3
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Agénor M, Geffen SR, Zubizarreta D, Jones R, Giraldo S, McGuirk A, Caballero M, Gordon AR. Experiences of and resistance to multiple discrimination in health care settings among transmasculine people of color. BMC Health Serv Res 2022; 22:369. [PMID: 35307008 PMCID: PMC8935683 DOI: 10.1186/s12913-022-07729-5] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/03/2022] [Indexed: 12/09/2023] Open
Abstract
Background Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited. Methods Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience—and resist—multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18–25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants’ experiences of health care discrimination were clustered into themes and sub-themes. Results Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination—both independently and simultaneously—in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. Discussion Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07729-5.
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Affiliation(s)
- Madina Agénor
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA. .,Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, RI, USA. .,The Fenway Institute, Fenway Health, Boston, MA, USA.
| | - Sophia R Geffen
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.,Center for Health Equity Education and Advocacy, Cambridge Health Alliance, Cambridge, MA, USA
| | - Dougie Zubizarreta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Raquel Jones
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Shane Giraldo
- Department of Sociology, Simmons University, Boston, MA, USA.,Youth Community Advisory Board, Tufts University, Medford, MA, USA
| | - Allison McGuirk
- Department of Counseling Psychology, University of Wisconsin Madison, Madison, WI, USA
| | - Mateo Caballero
- Youth Community Advisory Board, Tufts University, Medford, MA, USA.,Department of Communication Studies, Northeastern University, Boston, MA, USA
| | - Allegra R Gordon
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.,Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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4
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Emery EH, Shaffer JD, McCormick D, Zeidman J, Geffen SR, Stojicic P, Ganz M, Basu G. Preparing Doctors in Training for Health Activist Roles: A Cross-Institutional Community Organizing Workshop for Incoming Medical Residents. MedEdPORTAL 2022; 18:11208. [PMID: 35106380 PMCID: PMC8763867 DOI: 10.15766/mep_2374-8265.11208] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/22/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Physicians are increasingly being called on to address inequities created by social and structural determinants of health, yet few receive training in specific leadership skills that allow them to do so effectively. METHODS We developed a workshop to introduce incoming medical interns from all specialties at Boston-area residency programs to community organizing as a framework for effective physician advocacy. We utilized didactic sessions, video examples, and small-group practice led by trained coaches to familiarize participants with one community organizing leadership skill-public narrative-as a means of creating the relationships that underlie collective action. We offered this 3-hour, cross-institutional workshop just prior to intern orientation and evaluated it through a postworkshop survey. RESULTS In June 2019, 51 residents from 13 programs at seven academic medical centers attended this workshop. In the postworkshop survey, participants agreed with positive evaluative statements about the workshop's value and impact on their knowledge, with a mean score on all items of over 4 (5-point Likert scale, 1 = strongly disagree, 5 = strongly agree; response rate: 34 of 51). Free-text comments emphasized the workshop's effectiveness in evoking positive feelings of solidarity, community, and professional identity. DISCUSSION The workshop effectively introduced participants to community organizing and public narrative, allowed them to apply the principles of public narrative by developing their own stories of self, and demonstrated how these practices can be utilized in physician advocacy. The workshop also connected participants to their motivations for pursuing medicine and stimulated interest in more community organizing training.
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Affiliation(s)
- Eleanor H. Emery
- Program Officer, Center for Health Equity Education and Advocacy, Cambridge Health Alliance; Instructor of Medicine, Part-time, Harvard Medical School; Medical Officer-Physician, Department of Internal Medicine, Northern Navajo Medical Center
| | | | - Danny McCormick
- Co-Director, Center for Health Equity Education and Advocacy, Cambridge Health Alliance; Associate Professor of Medicine, Harvard Medical School
| | - Jessica Zeidman
- Primary Care Program Director, Department of Internal Medicine, Massachusetts General Hospital; Instructor of Medicine, Harvard Medical School
| | - Sophia R. Geffen
- Program Manager, Center for Health Equity Education and Advocacy, Cambridge Health Alliance
| | - Predrag Stojicic
- Instructor, Harvard T.H. Chan School of Public Health; Program Director for Community Organizing, Center for Health Equity Education and Advocacy, Cambridge Health Alliance; Executive Director, People Power Health
| | - Marshall Ganz
- Rita E. Hauser Senior Lecturer in Leadership, Organizing, and Civil Society, Harvard Kennedy School
| | - Gaurab Basu
- Co-Director, Center for Health Equity Education and Advocacy, Cambridge Health Alliance; Instructor of Medicine, Harvard Medical School
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5
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Powell TW, Jo M, Smith AD, Marshall BD, Thigpen S, Offiong A, Geffen SR. Supplementing Substance Use Prevention With Sexual Health Education: A Partner-Informed Approach to Intervention Development. Health Promot Pract 2022; 23:109-117. [DOI: 10.1177/1524839920947683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Supplementing substance use prevention with sexual health education would allow educators to address the risk and protective factors that influence both health issues. This streamlined approach may minimize the inefficiencies of multisession, single-purpose interventions. Our team developed a supplemental sexual and reproductive health (SRH) unit to align with an existing evidence-based intervention, LifeSkills Training (LST). This goal of this article is to describe our process, final product, lessons learned, and future directions. Our partner-informed approach took place across three key phases: (1) formative insights, (2) unit development, and (3) pilot implementation. The final supplemental SRH unit is ten, 45-minute sessions offered to seventh- and eighth-grade students and includes a set of learning objectives that are aligned with individual sessions. The supplemental SRH unit also mirrors existing LST modules in length, flow, layout, facilitator instructions, focus on prevention, and utilization of a student workbook. Lessons learned include strategies to effectively incorporate a wide range of ongoing feedback from multiple sources and quickly respond to staff turnover. This partnership approach serves as a model for researchers and practitioners aiming to extend the reach of existing evidence-based programs.
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Affiliation(s)
| | - Meghan Jo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne D. Smith
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Beth D. Marshall
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Santha Thigpen
- Maree G. Farring Elementary/Middle School, Baltimore, MD, USA
| | - Asari Offiong
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Cahill SR, Wang TM, Fontenot HB, Geffen SR, Conron KJ, Mayer KH, Johns MM, Avripas SA, Michaels S, Dunville R. Perspectives on Sexual Health, Sexual Health Education, and HIV Prevention From Adolescent (13-18 Years) Sexual Minority Males. J Pediatr Health Care 2021; 35:500-508. [PMID: 34154868 PMCID: PMC8419154 DOI: 10.1016/j.pedhc.2021.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 02/11/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. METHOD Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. RESULTS Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: 1: identity formation and sources of support, 2: challenges to obtaining sexual health information, 3: attitudes/beliefs about sex and sexual behaviors, and 4: barriers to HIV prevention. DISCUSSION These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.
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Affiliation(s)
- Sean R Cahill
- Sean R. Cahill, Director of Health Policy Research, The Fenway Institute, Fenway Health; Adjunct Associate Professor of the Practice, Department of Health Law, Policy and Management, Boston University School of Public Health; Affiliate Associate Clinical Professor and Visiting Scholar, Bouve College of Health Sciences, Northeastern University, Boston, MA.
| | - Timothy M Wang
- Timothy M. Wang, Director of Policy and Advocacy, Howard Brown Health Center, Chicago, IL
| | - Holly B Fontenot
- Holly B. Fontenot, Affiliated Faculty, The Fenway Institute, Fenway Health, Boston, MA and Associate Professor & Frances A. Matsuda Chair in Women's Health, School of Nursing & Dental Hygiene, University of Hawaii at Manoa, Honolulu, HI
| | - Sophia R Geffen
- Sophia R. Geffen, HIV Prevention Research Project Manager, The Fenway Institute, Fenway Health, Boston, MA
| | - Kerith J Conron
- Kerith Conron, Blachford-Cooper Research Director and Distinguished Scholar, The Williams Institute, UCLA School of Law, Los Angeles, CA
| | - Kenneth H Mayer
- Kenneth H. Mayer, Medical Research Director and Co-Director, The Fenway Institute, Fenway Health; Professor of Medicine, Harvard Medical School; Attending Physician, Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michelle M Johns
- Michelle M. John, Health Scientist, Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sabrina A Avripas
- Sabrina A. Avripas, Senior Research Director, Public Health, NORC at the University of Chicago, Chicago, IL
| | - Stuart Michaels
- Stuart Michaels, Senior Research Scientist, Ogburn-Stouffer Center for the Study of Social Organizations, NORC at the University of Chicago, Chicago, IL
| | - Richard Dunville
- Richard Dunville, Deputy Director, Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, GA
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Dean LT, Greene N, Adams MA, Geffen SR, Malone J, Tredway K, Poteat T. Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women. Psychooncology 2021; 30:1145-1150. [PMID: 33689190 PMCID: PMC8273081 DOI: 10.1002/pon.5670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/17/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening. METHODS This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011. RESULTS Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity. CONCLUSIONS SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.
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Affiliation(s)
- Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Naomi Greene
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mary Anne Adams
- ZAMI NOBLA: National Organization of Black Lesbians on Aging, East Point, Georgia, USA
| | - Sophia R. Geffen
- Center for Health Equity Education & Advocacy, Cambridge Health Alliance, Cambridge, Massachusetts, USA
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kristi Tredway
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tonia Poteat
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Social Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
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Cahill SR, Keatley J, Wade Taylor S, Sevelius J, Elsesser SA, Geffen SR, Wang T, Mayer KH. "Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco. AIDS Care 2019; 32:585-593. [PMID: 31482726 DOI: 10.1080/09540121.2019.1659912] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 10/26/2022]
Abstract
Transgender women (TW) are disproportionately affected by HIV. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce TW's vulnerability to HIV, but PrEP uptake has been limited among TW. To explore barriers to PrEP uptake, the study team conducted two semi-structured focus groups with TW in San Francisco at risk for HIV acquisition. A within-case, across-case approach was used to code and analyze emerging themes. Focus group participants were racially and ethnically diverse. A few participants in both groups had heard of PrEP, but some had not. Several said that their health care providers had not told them about PrEP. Participants in both groups had questions about side effects. They expressed medical mistrust and said poverty is an important context for their lives. They described a need for gender affirming health care services and raised concerns about interactions of PrEP with feminizing hormones. Information about side effects and interactions between gender affirming hormones and PrEP need to be explicitly addressed in PrEP education campaigns focusing on TW. Health care institutions and health departments should train clinical staff how to provide affirming care. Gender identity nondiscrimination laws and policies could improve transgender people's ability to earn a living and access health care.
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Affiliation(s)
- Sean R Cahill
- The Fenway Institute, Fenway Health, Boston, MA, USA.,Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - JoAnne Keatley
- Center of Excellence for Transgender Health, University of California San Francisco, San Francisco, CA, USA
| | - S Wade Taylor
- The Fenway Institute, Fenway Health, Boston, MA, USA.,School of Social Work, Boston University, Boston, MA, USA
| | - Jae Sevelius
- Center of Excellence for Transgender Health, University of California San Francisco, San Francisco, CA, USA
| | - Steven A Elsesser
- The Fenway Institute, Fenway Health, Boston, MA, USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Tim Wang
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Boston, MA, USA
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