ArticlePublisher preview available

Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia

DOI:10.1007/s10461-022-03701-w
Authors:
Elle Lett
Elle Lett
Elle Lett
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Emmanuella Ngozi Asabor
Emmanuella Ngozi Asabor
Emmanuella Ngozi Asabor
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Nguyen Tran
Nguyen Tran
Nguyen Tran
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Nadia Dowshen at The Children's Hospital of Philadelphia
Nadia Dowshen
Show all 7 authorsHide
Read publisher preview
Download citation
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18–30 years (N = 228). Racism was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index, respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC. We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC. Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.
  • A preview of this full-text is provided by Springer Nature.
  • Learn more
Preview content only
Content available from AIDS and Behavior
This content is subject to copyright. Terms and conditions apply.
Vol.:(0123456789)
1 3
AIDS and Behavior
https://doi.org/10.1007/s10461-022-03701-w
ORIGINAL PAPER
Sexual Behaviors Associated withHIV Transmission Among
Transgender andGender Diverse Young Adults: The Intersectional Role
ofRacism andTransphobia
ElleLett1,2 · EmmanuellaNgoziAsabor3,4· NguyenTran5· NadiaDowshen6,7· JayaAysola8,9·
AllegraR.Gordon10,11· MadinaAgénor12,13
Accepted: 28 April 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022
Abstract
HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people
of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and
transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and
sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard
errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and
sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18–30years (N = 228). Racism
was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index,
respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale
and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and
interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC.
We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug
consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC.
Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce
discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.
Keywords Transgender· Race and structural racism· Transphobia· Intersectionality· Systemic discrimination
* Elle Lett
elle.lett@pennmedicine.upenn.edu
1 Center forApplied Transgender Studies, Chicago, IL, USA
2 Perelman School ofMedicine, University ofPennsylvania,
Blockley Hall, Philadelphia, PA19146, USA
3 Yale School ofPublic Health, NewHaven, CT, USA
4 Yale School ofMedicine, NewHaven, CT, USA
5 Department ofEpidemiology andBiostatistics, Dornsife
School ofPublic Health, Drexel University, Philadelphia, PA,
USA
6 Department ofPediatrics, Perelman School ofMedicine,
University ofPennsylvania, Philadelphia, PA, USA
7 Craig‑Dalsimer Division ofAdolescent Medicine, Children’s
Hospital ofPhiladelphia, Philadelphia, PA, USA
8 Division ofGeneral Internal Medicine, Perelman School
ofMedicine, University ofPennsylvania, Philadelphia, PA,
USA
9 Office ofInclusion, Diversity, andEquity, Perelman School
ofMedicine, University ofPennsylvania, Philadelphia, PA,
USA
10 Department ofCommunity Health Sciences, Boston
University School ofPublic Health, Boston, MA, USA
11 Division ofAdolescent/Young Adult Medicine, Boston
Children’s Hospital, Boston, MA, USA
12 Department ofBehavioral andSocial Sciences, Brown
School ofPublic Health, Providence, RI, USA
13 The Fenway Institute, Fenway Health, Boston, MA, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
ResearchGate has not been able to resolve any citations for this publication.
Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review
Article
Full-text available
  • Jun 2020
Background Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries. Methods We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Findings Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01–1·26]) and high support needs (RR 1·42 [1·19–1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear. Interpretation Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes. Funding Inner City Health Associates.
Intersecting Structural Oppression and Suicidality Among Black Sexual Minority Male Adolescents and Emerging Adults
Article
  • Feb 2022
This study examined associations between structural racism, anti-LGBTQ policies, and suicide risk among young sexual minority men (SMM). Participants were a 2017-2018 Internet-based U.S. national sample of 497 Black and 1536 White SMM (ages 16-25). Structural equation modeling tested associations from indicators of structural racism, anti-LGBTQ policies, and their interaction to suicide risk factors. For Black participants, structural racism and anti-LGBTQ policies were significantly positively associated with depressive symptoms, heavy drinking, perceived burdensomeness, thwarted belongingness, self-harm, and suicide attempt. There were significant interaction effects: Positive associations between structural racism and several outcomes were stronger for Black participants in high anti-LGBTQ policy states. Structural racism, anti-LGBTQ policies, and their interaction were not significantly associated with suicide risk for White SMM.
Ending the HIV epidemic for all, not just some: structural racism as a fundamental but overlooked social-structural determinant of the US HIV epidemic
Article
  • Jan 2022
Purpose of review: We review the recent theoretical and empirical literature on structural racism, social determinants of health frameworks within the context of HIV prevention and treatment, and criticism of the national responses to the US epidemic. Recent findings: In line with growing mainstream attention to the role of structural racism and health inequities, recent editorials and studies cite ending structural racism as an essential step to ending the US HIV epidemic. Recent studies demonstrate that barriers rooted in structural racism such as incarceration, housing instability, police discrimination, neighborhood disadvantage, health service utilization and community violence, and poor or no access to social services, transportation, and childcare, are barriers to HIV prevention. Recent articles also criticize national responses to HIV such as the ending the HIV epidemic (EHE) and National HIV/AIDS Strategy plans for failing to address structural racism and prioritize community engagement in EHE efforts. Summary: Collectively, the articles in this review highlight a growing consensus that the US has no real chance of EHE for all, absent a meaningful and measurable commitment to addressing structural racism and intersectional discrimination as core determinants of HIV, and without more equitable engagement with community-based organizations and communities disproportionately affected by HIV.
Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research
Article
  • Jan 2022
Differences in health outcomes across racial groups are among the most commonly reported findings in health disparities research. Often, these studies do not explicitly connect observed disparities to mechanisms of systemic racism that drive adverse health outcomes among racialized and other marginalized groups in the United States. Without this connection, investigators inadvertently support harmful narratives of biologic essentialism or cultural inferiority that pathologize racial identities and inhibit health equity. This paper outlines pitfalls in the conceptualization, contextualization, and operationalization of race in quantitative population health research and provides recommendations on how to appropriately engage in scientific inquiry aimed at understanding racial health inequities. Race should not be used as a measure of biologic difference, but rather as a proxy for exposure to systemic racism. Future studies should go beyond this proxy use and directly measure racism and its health impacts.
Structural Intersectionality as a New Direction for Health Disparities Research
Article
  • Aug 2021
This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism—which point to promising new ways to measure systems of inequality at a macro level—to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.
Intercategorical and Intracategorical Experiences of Discrimination and HIV Prevalence Among Transgender Women in San Francisco, CA: A Quantitative Intersectionality Analysis
Article
  • Jan 2021
Objectives. To examine differences in HIV prevalence and experiences of discrimination within the trans women community in California’s San Francisco Bay Area. Methods. Intersectional positions were constructed on the basis of race/ethnicity (non-Hispanic White, non-Hispanic Black, Latina) and gender identity (female identifying, transgender identifying). We used baseline data from the Trans*National study (2016–2017) to construct regression models that estimated racial/ethnic differences in the attribution of discrimination experienced and, along with surrogate measures for intersectionality, estimated risk among those who were dually marginalized (racial/ethnic minority and transgender identifying). Margins plots were used to visually compare absolute risk across all intersectional positions. Results. Black and Latina trans women were more likely to be HIV positive than non-Hispanic White trans women. In several of the study domains, we estimated a lower risk of reporting discrimination among dually marginalized trans women than among White female-identifying trans women. Conclusions. Quantitative intersectionality methods highlight the diversity of experiences within the trans women community and reveal potential measurement challenges. Despite facing multiple forms of systemic marginalization, racial/ethnic minority trans women report less discrimination than White trans women. Subjective reporting of discrimination likely undercounts risks among racial/ethnic minorities. (Am J Public Health. Published online ahead of print January 21, 2021: e1–e11. https://doi.org/10.2105/AJPH.2020.306055 )
Characterizing Health Inequities for the U.S. Transgender Hispanic Population Using the Behavioral Risk Factor Surveillance System
Article
  • Dec 2020
Purpose: This study aims to describe health inequities experienced by transgender Hispanic (TH) individuals in the United States. Methods: This retrospective case-control study used the Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 to 2018. Propensity score matching and logistic and negative binomial regression were used to compare TH survey respondents with other relevant populations across the following outcomes: health care access, health risk factors, self-reported chronic conditions, and perceived health status. Results: Relative to transgender White (TW) respondents, TH respondents (n=414) were less likely to report having health insurance (odds ratio [OR]: 0.35, p<0.001), a regular provider (OR=0.40, p<0.001), and were more likely to report cost barriers to care (OR=1.85, p<0.001) and HIV risk factors (OR=2.41, p<0.001). Similar results were found when comparing outcomes with cisgender White respondents. TH respondents reported fewer days of poor health (rate ratio [RR]=0.67, p<0.001), activity limited days (RR=0.64, p=0.011), and were less likely to report depression (OR=0.44, p<0.001) than TW respondents. Relative to cisgender Hispanic (CH) respondents, TH respondents experienced more cost barriers (OR=1.56, p=0.003), higher HIV risk (OR=3.38, p<0.001), and more activity limited days (RR=2.93, p<0.001). Conclusion: Our results demonstrate that TH individuals may be less likely to have access to health care and have poorer health-related quality-of-life when compared with either CH or TW individuals. It is vital that additional research further elucidate the challenges faced by this multiply marginalized population including racism and transphobia. Further health care solutions should be responsive to the unique challenges of the TH population at the individual and institutional level.
Various Versatile Variances: An Object-Oriented Implementation of Clustered Covariances in R
Article
Intersectionality and Health Inequities for Gender Minority Blacks in the U.S
Article
Introduction Gender minority blacks represent the intersection of multiply marginalized populations that experience severe health inequities in the U.S. However, few studies focus on the unique health experiences of this multiply disadvantaged population. This study quantifies the health inequities experienced by gender minority blacks in the U.S. using an intersectional framework. Methods This cross-sectional study analyzed data in 2018/2019 from the Behavioral Risk Factor Surveillance System, including all cisgender black, gender minority black, and gender minority white survey respondents who completed the gender identity module between 2014 and 2018. Investigators compared demographics, healthcare access, behavioral risk factors, chronic conditions, and perceived health status of gender minority blacks with those of cisgender blacks and gender minority whites. Results In the primary analysis of weighted survey data, gender minority blacks were more likely to report experiencing severe mental distress (AOR=1.99, 95% CI=1.14, 3.47, p=0.02), longer periods of being physically or mentally unwell (adjusted RR=1.36, 95% CI=1.17, 1.59, p<0.001), and longer periods of activity limitations owing to poor health (adjusted RR=1.53, 95% CI=1.01, 1.41, p=0.003) than cisgender blacks. In a matched analysis, gender minority blacks had worse self-reported health than both cisgender blacks (OR=1.32, 95%: CI=1.05, 1.67, p=0.02) and gender minority whites (OR=1.53, 95% CI=1.15, 2.04, p=0.003). Conclusions Gender minority blacks have health experiences that are distinct from those of both the cisgender black and gender minority populations with which they intersect. Health policies and programs, including data collection efforts, must specifically consider this multiply marginalized population to effectively advance health equity.
Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates
Article
  • Jul 2020
Background: Transgender individuals experience unique vulnerabilities to intimate partner violence (IPV) and may experience a disproportionate IPV burden compared with cisgender (nontransgender) individuals. Objectives: To systematically review the quantitative literature on prevalence and correlates of IPV in transgender populations. Search Methods: Authors searched research databases (PubMed, CINAHL), gray literature (Google), journal tables of contents, and conference abstracts, and consulted experts in the field. Authors were contacted with data requests in cases in which transgender participants were enrolled in a study, but no disaggregated statistics were provided for this population. Selection Criteria: We included all quantitative literature published before July 2019 on prevalence and correlates of IPV victimization, perpetration, or service utilization in transgender populations. There were no restrictions by sample size, year, or location. Data Collection and Analysis: Two independent reviewers conducted screening. One reviewer conducted extraction by using a structured database, and a second reviewer checked for mistakes or omissions. We used random-effects meta-analyses to calculate relative risks (RRs) comparing the prevalence of IPV in transgender individuals and cisgender individuals in studies in which both transgender and cisgender individuals were enrolled. We also used meta-analysis to compare IPV prevalence in assigned-female-sex-at-birth and assigned-male-sex-at-birth transgender individuals and to compare physical IPV prevalence between nonbinary and binary transgender individuals in studies that enrolled both groups. Main Results: We identified 85 articles from 74 unique data sets (n total = 49 966 transgender participants). Across studies reporting it, the median lifetime prevalence of physical IPV was 37.5%, lifetime sexual IPV was 25.0%, past-year physical IPV was 16.7%, and past-year sexual IPV was 10.8% among transgender individuals. Compared with cisgender individuals, transgender individuals were 1.7 times more likely to experience any IPV (RR = 1.66; 95% confidence interval [CI] = 1.36, 2.03), 2.2 times more likely to experience physical IPV (RR = 2.19; 95% CI = 1.66, 2.88), and 2.5 times more likely to experience sexual IPV (RR = 2.46; 95% CI = 1.64, 3.69). Disparities persisted when comparing to cisgender women specifically. There was no significant difference in any IPV, physical IPV, or sexual IPV prevalence between assigned-female-sex-at-birth and assigned-male-sex-at-birth individuals, nor in physical IPV prevalence between binary- and nonbinary-identified transgender individuals. IPV victimization was associated with sexual risk, substance use, and mental health burden in transgender populations. Authors’ Conclusions: Transgender individuals experience a dramatically higher prevalence of IPV victimization compared with cisgender individuals, regardless of sex assigned at birth. IPV prevalence estimates are comparably high for assigned-male-sex-at-birth and assigned-female-sex-at-birth transgender individuals, and for binary and nonbinary transgender individuals, though more research is needed. Public Health Implications: Evidence-based interventions are urgently needed to prevent and address IPV in this high-risk population with unique needs. Lack of legal protections against discrimination in employment, housing, and social services likely foster vulnerability to IPV. Transgender individuals should be explicitly included in US Preventive Services Task Force recommendations promoting IPV screening in primary care settings. Interventions at the policy level as well as the interpersonal and individual level are urgently needed to address epidemic levels of IPV in this marginalized, high-risk population. (Am J Public Health. Published online ahead of print July 16, 2020: e1–e14. doi:10.2105/AJPH.2020.305774)