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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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Wiginton JM, Murray SM, Algarin AB, Baral SD, Sanchez TH, Smith LR. Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses. BMC Infect Dis 2022; 22:690. [PMID: 35964006 PMCID: PMC9375942 DOI: 10.1186/s12879-022-07672-0] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/01/2022] [Indexed: 11/24/2022] Open
Abstract
Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.
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Affiliation(s)
- John Mark Wiginton
- School of Social Work, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA.
- Department of Medicine, University of California-San Diego, San Diego, USA.
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Angel B Algarin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, San Diego, USA
| | - Stefan D Baral
- Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Travis H Sanchez
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Laramie R Smith
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, San Diego, USA
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Zhao Y, Rao A, Wirtz AL, Umar E, Trapence G, Jumbe V, Ketende S, Kamba D, Beyrer C, Baral S. A structural equation model of factors associated with HIV risk behaviors and mental health among men who have sex with men in Malawi. BMC Infect Dis 2020; 20:591. [PMID: 32778057 PMCID: PMC7419207 DOI: 10.1186/s12879-020-05310-1] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 07/30/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Men who have sex with men (MSM) bear a disproportionate burden of HIV in Malawi. Early prevention efforts in Malawi have been largely focused on preventing heterosexual and vertical transmission of HIV, and MSM have rarely been the specific benefactors of these efforts, despite facing both higher prevalence of HIV coupled with multiple barriers to prevention and care. To better facilitate the design of culturally relevant HIV prevention programs and prioritize resources among MSM in resource limited settings, the objective of this analysis was to estimate the relationship between social factors and HIV related risk behaviors and mental health. METHODS 338 MSM were recruited using respondent-driven sampling in Blantyre, Malawi from April 2011 to March 2012. Structural equation models were built to test the association between six latent factors: participation in social activities, social support, stigma and human rights violations, depression symptomatology, condom use, and sexual risk behaviors, including concurrent sexual partnerships and total number of partners. RESULTS The mean age of participants was 25 years old. Almost 50% (158/338) of the participants were unemployed and 11% (37/338) were married or cohabiting with women. More than 30% (120/338) of the participants reported sexual behavior stigma and 30% (102/338) reported depression symptomatology. Almost 50% (153/338) of the participants reported any kind of HIV-related risk behaviors and 30% (110/338) participated in one of the recorded social activities. Significant associations were identified between stigma and risk behaviors (β = 0.14, p = 0.03); stigma and depression symptomatology (β = 0.62, p = 0.01); participation in social activities and depression symptomatology (β = 0.17, p = 0.01). CONCLUSION Results suggest MSM reporting stigma are more likely to report sexual risk practices associated with HIV/STI transmission and depressive symptoms, while those reporting participation in social activities related to HIV education are less likely to be depressed. Furthermore, interventions at the community level to support group empowerment and engagement may further reduce risks of HIV transmission and improve mental health outcomes. Taken together, these results suggest the potential additive benefits of mental health services integrated within comprehensive HIV prevention packages to optimize both HIV-related outcomes and general quality of life among MSM in Malawi.
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Affiliation(s)
- Yuan Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Amrita Rao
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Andrea L Wirtz
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Eric Umar
- Department of Health Systems and Policy Development, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Vincent Jumbe
- Department of Health Systems and Policy Development, University of Malawi College of Medicine, Blantyre, Malawi
- Center for Global Health, Trinity College, Dublin, Ireland
| | - Sosthenes Ketende
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Dunker Kamba
- Center for Development of People, Blantyre, Malawi
| | - Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Maksut JL, Sanchez TH, Wiginton JM, Scheim AI, Logie CH, Zlotorzynska M, Lyons CE, Baral SD. Gender identity and sexual behavior stigmas, severe psychological distress, and suicidality in an online sample of transgender women in the United States. Ann Epidemiol 2020; 52:15-22. [PMID: 32768521 DOI: 10.1016/j.annepidem.2020.07.020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/10/2020] [Accepted: 07/28/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE The objective of this study is to (1) quantify burden of perceived, anticipated, and enacted gender identity (GI) and sexual behavior (SB) stigmas and (2) explore associations between GI and SB stigmas with key mental health factors among transgender women in the United States. METHODS We estimated associations between GI and SB stigmas with severe psychological distress, suicidal ideation, and suicide attempt using cross-sectional data from the Transgender Women's Internet Survey and Testing study from March to April, 2019. Modified Poisson regression produced prevalence ratios and 95% confidence intervals for severe psychological distress, suicidal ideation, and suicide attempt with GI and SB stigma items individually, as well as the GI and SB stigma items treated as two scales. RESULTS Of 381 transgender women, 52% experienced severe psychological distress in the past month, whereas 59.3% and 13.12% reported suicide ideation and attempt in the past year, respectively. In adjusted models, GI and SB stigma scales were significantly, positively associated with severe psychological distress, suicidal ideation, and suicide attempt. CONCLUSIONS Continued training for providers in trans-competent mental health care and the development of newer engagement and delivery strategies for stigma mitigation interventions are needed.
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