Abstract

It is too early for me to be getting misgendered"": A qualitative exploration of healthcare experiences among transgender people in New Jersey

Caleb LoSchiavo, MPH, Connor Emmert, MPH Rutgers School of Public Health

APHA 2022 Annual Meeting and Expo

Background: Transgender people face extensively-documented health disparities compared to their cisgender peers. While a great deal of research has explored these inequities, more research is needed to better understand their drivers, including what prevents transgender people from seeking healthcare. As such, this analysis sought to explore what transgender people in New Jersey (NJ) face when accessing healthcare.
Methods: As part of a larger qualitative study on human papillomavirus-related healthcare experiences, transgender adults living in NJ completed semi-structured interviews exploring their general healthcare experiences. Qualitative analysis was conducted in Dedoose and guided by Braun and Clarke's thematic analysis.
Results: Our analysis found that, even when transgender people do overcome the barriers to accessing care, they face numerous negative experiences, including gatekeeping, misgendering, lack of LGBTQ-competence, and implicit and explicit transphobia and homophobia. We also found that participants often had a low bar for what they considered to be positive or affirming care, such as providers listening and not judging them. When participants described truly affirming experiences, these were often LGBTQ-identified providers and providers who went above and beyond to provide quality care.
Conclusion: Transgender participants recounted a variety of negative experiences in healthcare, ranging from microaggressions to structural and systemic forms of bias. Participants' descriptions of positive encounters reflected how frequently their healthcare providers cause harm, by framing the smallest acts of respect as affirmations. However, the genuinely affirming characteristics that participants described may provide helpful recommendations for healthcare providers and organizations to make their practice more trans-inclusive and affirming.

Abstract

Healthcare stereotype threat, healthcare utilization, and health outcomes in a probability sample of U.S. transgender and gender diverse adults

Merrily LeBlanc, BA¹, Mai-Han Trinh, MS², Dougie Zubizarreta, BA², Sari L. Reisner, ScD³ (1)The Fenway Institute, Fenway Health, (2)Department of Epidemiology, Harvard T.H. Chan School of Public Health, (3)The Fenway Institute, Fenway Health; Department of Epidemiology, Harvard T.H. Chan School of Public Health; Department of Medicine, Harvard Medical School; Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital

APHA 2022 Annual Meeting and Expo

Background: Health inequities among transgender and gender diverse (TGD) populations are well-documented and may be partially explained by fears and experiences of discrimination when seeking care. Healthcare stereotype threat (HCST) occurs when the threat of being perceived negatively based on identity-related stereotypes influences a patient’s behavior. Few studies have investigated associations between HCST, healthcare utilization, and health outcomes among TGD individuals.

Methods: We analyzed the U.S. Transgender Population Health Survey, a cross-sectional national probability sample of 274 TGD adults recruited April 2016–December 2018. Participants self-reported HCST through a 4-item scale (scores 1-5 with higher scores indicating greater HCST). We estimated prevalence ratios (PR) for the association between HCST and binary healthcare access indicators and health outcomes using Poisson models with robust variance. Incidence rate ratios (IRR) were estimated using negative binomial models for the association between HCST and number of past-month poor physical and mental health days. Models adjusted for sociodemographic and medical gender affirmation characteristics.

Results: HCST threat was associated with increased prevalence of not having a personal doctor/healthcare provider (PR=1.25; 95%CI:1.00-1.56) and reporting fair/poor general health vs good/very good/excellent health (PR=1.92; 95%CI:1.37-2.70). Higher HCST was also associated with more frequent past-month poor physical (IRR=1.34; 95%CI:1.12-1.59) and mental (IRR=1.49; 95%CI:1.33-1.66) health days. Significant associations were not detected for other healthcare access indicators (e.g., being uninsured).

Discussion: HCST may contribute to adverse health and healthcare access outcomes in TGD populations, though prospective studies are needed. Multilevel interventions are recommended to create safe, gender-affirming healthcare environments that mitigate HCST.

Abstract

Associations between diverse types of transgender-related stigma and mental health outcomes in Lima, Peru

Courtney O'Connor¹, Alfonso Silva-Santisteban², Amaya Perez-Brumer³, Carlos F Cáceres⁴, Lance Pollack⁵, Eddy R Segura⁶, Jordan E Lake⁷, Jesse L Clark⁸, Susan M Kegeles⁹, Kelika Konda⁸ (1)South American Program in HIV Prevention Research, University of California Los Angeles, CA, USA, (2)Center for Interdisciplinary Research On Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru, (3)The University of Toronto, Dalla Lana School of Public Health, Toronto, ON, Canada, (4)Center for Interdisciplinary Studies in Sexuality, AIDS and Society, Universidad Peruana Cayetano Heredia, Lima, Peru, (5)Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA, (6)South American Program in HIV Prevention Research (SAPHIR), Department of Medicine, University of California Los Angeles, CA, USA, (7)Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA, (8)UCLA David Geffen School of Medicine, Los Angeles, CA, USA, (9)Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA

APHA 2022 Annual Meeting and Expo

OBJECTIVE: To assess how different types of stigma experienced as the result of transgender identity are associated with social isolation and depression among an urban community-based sample of transgender women in Lima, Peru. Specifically, we examined healthcare stigma (related to experiences with healthcare providers and services), social stigma (interpersonal encounters with friends, family, or strangers), and internalized stigma (acceptance and application of negative messages to oneself).

METHODS: This sample was derived from a bio-behavioral survey assessing HIV care and prevention needs of transgender women in 2017. Healthcare, social, and internalized stigma and social isolation (outcome 1) were each coded as a sum score of items from established scales. Depression (outcome 2) was indicated by a CES-D scale score of 16+. We assessed the association of each type of stigma with social isolation and depression using linear regression and Poisson models, respectively. Final models controlled for age, education, income, and self-reported HIV serostatus.

RESULTS: Respondents (n=135) had mean age of 31.9 years and HIV prevalence of 35.7%. Among the final adjusted models, healthcare, social, and internalized stigma were each associated with increased social isolation (a𝛽=0.20, 95%CI:0.02-0.38; a𝛽=0.14; 95%CI:0.07-0.22; a𝛽=0.09, 95%CI:0.04-0.14), respectively, and increased prevalence of depression (aPR=1.09, 95%CI:1.02-1.1; aPR=1.05, 95%CI:1.01-1.08; aPR=1.03, 95%CI:1.01-1.06), respectively.

CONCLUSION: Transgender women may experience more social isolation and depression in connection with experiences of healthcare, social, and internalized stigma. Further work is needed to fully understand heterogenous forms of stigma within the lived experiences of transgender women, and to design interventions for reducing stigma at multiple levels.

Abstract

Understanding the role of gender identity and cissexism in shaping HPV vaccination among transgender and gender diverse assigned female at birth young adults

Allison Rhodes, MD, MPH^1,2, Tara Ahmadi, MD, MPH², Madina Agénor, ScD, MPH³ (1)Tufts Medical Center, (2)Tufts University School of Medicine, (3)Brown University School of Public Health

APHA 2022 Annual Meeting and Expo

Background: Transgender and gender diverse assigned female at birth (AFAB) individuals experience notable barriers to cervical cancer screening, and may also face barriers to HPV vaccination, which provides primary prevention for HPV and cervical cancer. However, to date, no research has examined access to and utilization of HPV vaccination among transgender and gender diverse U.S. individuals. Methods: Using purposive sampling, we conducted semi-structured in-depth interviews with transgender and gender diverse AFAB young adults aged 18-26 years (n = 34). Interviews were transcribed and analyzed using thematic analysis. Results: The majority of participants identified structural barriers to HPV vaccination, including financial instability, non-matching identification leading to difficulty with insurance coverage, and structural oppression causing HPV vaccination to be of relatively low priority. Most reported significant barriers in the community, including gendered HPV vaccine marketing, incomprehensive sexual education, and the centering of cis gay men within queer spaces. Within healthcare itself, most participants reported provider-level barriers, including healthcare providers’ lack of knowledge about transgender health, and provider bias, stigma, and discrimination related to gender identity. Several participants identified additional individual barriers to HPV vaccination, including gender dysphoria associated with lower body parts and associating the HPV vaccine with pap smears and gendered healthcare spaces. Conclusion: Transgender and gender diverse young adults face notable barriers to HPV vaccination. HPV vaccine interventions tailored to transgender and gender diverse AFAB individuals’ experiences, including interventions that address cissexism at multiple levels in health care institutions in particular and society in general, are urgently needed.