State-level structural stigma and HIV risk behaviors among transgender individuals

OBJECTIVE: To assess whether stigmatizing social environments (i.e., structural stigma) were associated with HIV risk behaviors among transgender adults.

METHODS: State-level structural stigma was coded using a previously established measure (Hatzenbuehler, 2011) based on a 4-item composite index: (1) density of same-sex couples; (2) proportion of Gay-Straight Alliances per public high school; (3) 5 policies related to sexual orientation discrimination (e.g., same-sex marriage, employment non-discrimination); and (4) public opinion toward homosexuality (aggregated responses from 41 national polls). The index was linked to individual-level data from an online sample, collected in 2003, of transgender adults (mean age=32.7, SD=11.96) representing 48 states and the District of Columbia. Negative binomial generalized estimating equation (GEE) regression models explored whether state-level structural stigma was associated with HIV risk behaviors in the last 3 months among transgender adults.

RESULTS: Among the analytic sample of 947 respondents, 32.6% reported having unprotected anal intercourse (receptive or insertive) with any partner in the last 3 months (Mean=5.4 acts, SD=16.7). Lower levels of structural stigma were significantly associated with fewer unprotected sexual partners (Beta=0.98, SE=0.0, p<0.0001), controlling for sex, age, race/ethnicity, income, education, relationship status, and urbanicity.

CONCLUSION: Beyond individual-level risk factors, supportive state-level environments for sexual minorities may reduce the risk of HIV risk behaviors among transgender adults. Since there is currently sufficient variation in state-level policies targeting transgender populations (which was not available at the time this study was conducted), future studies should examine transgender-specific policies in order to replicate and extend our results.