Gender Affirmative Health Care: Terminology, Demographics, and … · 2019-12-05 · Sex and Gender...

Sari L. Reisner, ScDAssistant Professor of Pediatrics, Boston Children’s Hospital/Harvard Medical School

Assistant Professor of Epidemiology, Harvard T.H. Chan School of Public Health

Affiliated Research Scientist, Fenway Health

Gender Affirmative Health Care:

Terminology, Demographics,

and Epidemiology

Continuing Medical Education Disclosure Program Faculty: Sari Reisner, ScD

Current Position: Assistant Professor of Pediatrics, Harvard Medical School; Associate Scientific Researcher, Boston Children’s Hospital

Disclosure: No relevant financial relationships. Presentation does not include discussion of off-label products.

It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staffdisclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potentialconflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interestor who agree to an identified resolution process prior to their participation were involved in this CME activity.

2

Overview

Terminology: Sex, Gender, and Transgender

Global Health Burden in Transgender People

Situated Vulnerabilities

Participatory Population Perspective

3

Overview





4

Sex and Gender

5

Sex and gender core determinants of health

Sex – biological differences Anatomy, chromosomes, hormones,

genes, etc.

Gender – social and cultural distinctions mapped onto biology Multidimensional

Psychological, social, behavioral

Gender identity, gender expression, gender roles

Transgender

6

Gender identity or expression different than assigned sex at birth Male-to-Female (MTF), transgender women,

transgender girls, trans feminine (TF)

Female-to-Male (FTM), transgender men, transgender boys, trans masculine (TM)

Other diverse genders: genderqueer, nonbinary, bigender, gender expansive

Cultural variations (hijra, waria, travesti, trans)

Gender diversity ≠ pathology Approximately 25 million transgender people

worldwide

Gender Affirmation

Process by which individuals are affirmed in their gender identity or expression

Social

Psychological

Medical

Legal

Health and human rights

Self-determination

Recognition before the law

7

Gender Affirmation

http://www.thelancet.com/series/transgender-health

8

Standards of Care

9

Informed Consent

Fenway Health: Trans Health Program Growth, 1997-2015

10

N=11 N=41N=116

N=366

N=879

N=1208

N=1456

N=2017

0

500

1000

1500

2000

2500

1997 (EHR Starts in Use)

2000 ('04 THP Starts)

2005 ('06 New Coord.)

2009 ('07 New Protocols)

2012 ('10 New Pgm Asst.)

2013 (11/'12 New Med Dir)

2014 (New Pt Advocate)

2015 (Decentralization)

Nu

mb

er (

N)

of

Pati

ents

Fenway Health: Trans Health Program Growth, 1997-2015

11

N=11 N=41N=116

N=366

N=879

N=1208

N=1456

N=2017

0

500

1000

1500

2000

2500

1997 (EHR Starts in Use)

2000 ('04 THP Starts)

2005 ('06 New Coord.)

2009 ('07 New Protocols)

2012 ('10 New Pgm Asst.)

2013 (11/'12 New Med Dir)

2014 (New Pt Advocate)

2015 (Decentralization)

Nu

mb

er (

N)

of

Pati

ents

Gender Identity ≠ Sexual Orientation

Sexual orientation – how a person identifies their physical and emotional attraction to others

Transgender people can be of any sexual orientation

Cite: Grant et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Gay & Lesbian Task Force & National Transgender Center for Equality; 2011.

N > 6,450

12

Overview





13

Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD.

Global health burden and needs of transgender populations: a review.

Lancet 2016; 388(10042): 318-321.

14


Background

Need to characterize the global health burden facing transgender populations

Effectively prioritize the geography and content of transgender health research

15

Search, Selection Criteria, and Data Synthesis Review and synthesis of data from peer-reviewed scientific literature

PRISMA Guidelines

Inclusion criteria Published Jan 1, 2008 to Dec 20, 2014 inclusive Any study design, quantitative data, disease burden in trans people Pubmed, Embase, OVID, PsychInfo, Web of Science, ProQuest Search terms: - “transgender” (e.g., hijra, waria, travesti, female-to-male)

- health terms (e.g., HIV, disease, illness, mental health)

Title search, abstract review, full-text review, and data abstraction Completed by two reviewers, third reviewer as a tie-breaker Duplicates removed and excluding non-scientific journals

16

Global Health Burden: Studies in Transgender

Health, 2008-2014

17

116 studies

Number of Studies About Transgender Health

Published Per Year (n=116)

18

Distribution of Studies About Transgender

Health by Assigned Sex at Birth (n=116)

19

Health Outcome Categories in Transgender

Health (n=981 Data Points), 2008-2014

20

303

219193

10593

68

0

50

100

150

200

250

300

350

Mental Health Sexual andReproductive

Health

Substance Use Violence/Victimization

Stigma/Discrimination

GeneralHealth

Nu

mb

er

of

Dat

a P

oin

ts (

n)

Health Outcome Category

Limitations Excluded qualitative studies, a rich source of inquiry

Limited to peer-reviewed literature Many non-peer reviewed sources provide invaluable data

Partnerships between community members and researchers to collect data will improve research worldwide

Complex set of search terms and keywords to accurately identify current transgender health research “Transgender” added to PubMED as a MeSH term in 2013

21

Gaps and Opportunities No data or limited data in majority of the world

Need for shared lexicon and population definitions

Understudied health conditions (e.g., non-communicable diseases)

Lack of competent primary care and gender affirmation expertise

“Situated vulnerabilities” affect the health and wellbeing of

transgender populations globally

Increase the rigor and reach of

transgender public health research,

programming, practice, and policy

22

Overview





23

Global Burden of HIV in Transgender Women

Cite: Baral, Poteat, et al., The Lancet Infectious Diseases, 2013

Pooled HIV prevalence = 19.1% (95% CI 17.4–20.7) in

11,066 transgender women worldwide

24

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70315-8/fulltext?rss%3Dyes&ei=UMRkVaqrJJX-sASZhoCICA&psig=AFQjCNFGj2p0z-tRphHGZA8sHa4qOmBRRA&ust=1432753501835106

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70315-8/fulltext?rss%3Dyes&ei=UMRkVaqrJJX-sASZhoCICA&psig=AFQjCNFGj2p0z-tRphHGZA8sHa4qOmBRRA&ust=1432753501835106

Health Disparities

A particular type of difference in health…

“…in which disadvantaged social groups—such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination—systematically experience worse health or greater health risks than more advantaged social groups.”

Cite: Braveman P. Health disparities and health equity: Concepts and measurement. Ann Rev Public Health, 2006;27:167-194.

25

Social Stress Models (Minority Stress)

26

Social Disadvantage (Transgender)

Adverse Health

Cites: Hendricks & Testa, 2013; Meyer, 1995, 2003; Reisner et al., 2014

Social Stress Models (Minority Stress)

27

Social Disadvantage (Transgender)

Stressors

Adverse Health

a b

c

Cites: Hendricks & Testa, 2013; Meyer, 1995, 2003; Reisner et al., 2014

HIV

DiscriminationDepression

Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness

Sex Work Family, Peer Rejection

Violence

28

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

29

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

“Preventing HIV in us girls is complicated. We

need jobs, places to stay, doctors. HIV is just one of the many problems

we deal with.”– TF age 19

30

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

31




Mental Health: Transgender and Cisgender (Non-Transgender) Youth (n=360)

0

10

20

30

40

50

60

Depression Anxiety SuicideIdeation

SuicideAttempt

Self-Harm OutpatientMH Services

InpatientMH Services

Pe

rce

nt

(%)

Mental Health (MH)

Transgender Youth Non-Transgender Youth

Adjusted Risk Ratios Demonstrating Increased MH Burden: 2.36 to 4.30 (all p<0.01)

Reisner et al, J Adolescent Health, 2015 32

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

33



we deal with.”– MTF age 19

0

10

20

30

40

50

60

70

80

90

Any Bullying In Person By Phone Call Via TextMessage

Online Some OtherWay

We

igh

ted

Pe

rce

nt

(%)

Transgender Non-Transgender Female Non-Transgender Male

Past 12 Month Bullying Victimization

Adj. OR

(95% CI)

p-value

3.58 (2.74, 4.68)

<0.0001

2.93 (2.30, 3.72)

<0.0001

1.68 (1.29, 2.19)

<0.01

1.98 (1.55, 2.53)

<0.0001

3.02 (2.43, 3.75)

<0.0001

2.04 (1.62, 2.58)

<0.0001

Models adjusted for age,

race/ethnicity, family SES,

geographic context.

n=2260n=2840n=442

Reisner et al., J Sex Research, 2015 34

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

35




Discrimination in Healthcare: Project VOICE

Cite: Reisner et al. Legal protections in public accommodations settings: A critical public health issue for transgender and gender non-conforming people. Milbank Quarterly 2015; 93(3): 484-515.

36

Discrimination Shapes Healthcare Utilization 452 MA transgender adults - 24% discrimination in healthcare, last 12 mo

+Multivariable models adjusted for: discrimination in other settings, age, race/ethnicity, gender identity, natal sex, gender affirmation, visual gender nonconformity, income, education, employment, health insurance, survey mode.

13.9

24.8

30.3

4.4

8.9

1.8

0

5

10

15

20

25

30

35

Postponed care whenneeded, resulting in

emergency care

Postponed needed medicalcare when sick or injured

Postponed routinepreventive medical care

Pe

rce

nt

Discrimination No Discrimination

2.43 (1.92, 3.08)3.14 (2.63, 4.43)2.38 (1.76, 3.23)Adj. RR:

Discrimination definiton: Mistreatment on the basis of transgender or gender nonconforming

identity/presentation (included verbal harassment and physical assault).

37

Attributed Reasons for Everyday Discrimination

Experiences - Project VOICE

83.278.6

68

56.8

43.5

30.1 29.9

23.117.7

13.4 11.9 11.4 10.65.8

GenderIdentityand/or

Expression

HowMasculine or

FeminineYou Appear

SexualOrientation

Sex Age OtherAppearance

Weight Educationand/orIncome

Disability Religion Race Ethnicity OtherReason

Nationality

Pe

rce

nt

(%)

Attributed Reasons for Everyday Discrimination Experiences

Transgender and/or gender nonconforming MA residents ages 18 years or older

Mean (SD) = 4.8 (2.4)

[range 0-14]

Cite: Reisner et al. Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. Journal of Counseling Psychology; in press.

38

Multivariable Linear Model, PTSD Symptoms Beta (95% CI) p-value

Everyday Discrimination (cont.) 0.25 (0.21, 0.30) <0.0001

Number Reasons for Discrimination (cont.) 0.05 (0.01, 0.10) 0.015

Childhood Abuse Age < 15 years 0.29 (0.21, 0.37) <0.0001

IPV 0.18 (0.10, 0.26) <0.0001

Depression 0.23 (0.14, 0.32) <0.0001

Polydrug Use (2+) 0.13 (0.03, 0.23) 0.009

Age (continuous) -0.17 (-0.21, -0.12) <0.0001

FTM vs MTF -0.21 (-0.30, -0.11) <0.0001

Nonbinary Gender Identity vs Binary -0.03 (-0.13, 0.06) 0.493

Social Gender Affirmation (Live Full-Time) 0.13 (0.03, 0.23) 0.014

Medical Gender Affirmation (Hormones and/or Surgery) -0.10 (-0.19, -0.01) 0.043

High Visual GNC vs Moderate/Low 0.17 (0.08, 0.27) 0.0003

People of Color vs White Non-Hispanic -0.05 (-0.15, 0.05) 0.312

Income (cont.) -0.03 (-0.07, 0.02) 0.106

Education (cont.) -0.02 (-0.07, 0.01) 0.262

Unstably Housed vs Stably Housed 0.24 (0.15, 0.33) <0.0001

Sexual Minority (LGBQ) vs Heter0sexual 0.04 (-0.08, 0.15) 0.533

N=412 +Adjusted for survey mode (online vs in-person). All continuous variables z-scored.

44.4% probable PTSD 39

Beta (95% CI) p-value

Everyday Discrimination (cont.) 0.25 (0.21, 0.30) <0.0001

Number Reasons for Discrimination (cont.) 0.05 (0.01, 0.10) 0.015

Childhood Abuse Age < 15 years 0.29 (0.21, 0.37) <0.0001

IPV 0.18 (0.10, 0.26) <0.0001

Depression 0.23 (0.14, 0.32) <0.0001

Polydrug Use (2+) 0.13 (0.03, 0.23) 0.009

Age (continuous) -0.17 (-0.21, -0.12) <0.0001

FTM vs MTF -0.21 (-0.30, -0.11) <0.0001

Nonbinary Gender Identity vs Binary -0.03 (-0.13, 0.06) 0.493

Social Gender Affirmation (Live Full-Time) 0.13 (0.03, 0.23) 0.014

Medical Gender Affirmation (Hormones and/or Surgery) -0.10 (-0.19, -0.01) 0.043

High Visual GNC vs Moderate/Low 0.17 (0.08, 0.27) 0.0003

People of Color vs White Non-Hispanic -0.05 (-0.15, 0.05) 0.312

Income (cont.) -0.03 (-0.07, 0.02) 0.106

Education (cont.) -0.02 (-0.07, 0.01) 0.262

Unstably Housed vs Stably Housed 0.24 (0.15, 0.33) <0.0001

Sexual Minority (LGBQ) vs Heter0sexual 0.04 (-0.08, 0.15) 0.533

Multivariable Linear Model, PTSD Symptoms

N=412 +Adjusted for survey mode (online vs in-person). All continuous variables z-scored.

44.4% probable PTSD 40

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

41




U.S. Transgender Women (n=3,878)

0

5

10

15

20

25

30

35

40

45

50

Black Non-Hispanic

NativeAmerican/

AlaskanNative Non-

Hispanic

Public HealthInsurance

Uninsured Sex Work HIV-Infected SubstanceUse

PhysicalAssault

SexualAssault

Jail/Prison No Jail/Prison

Reisner, Bailey, Sevelius, Women Health, 2014

Single adjusted multivariable regression model included: Age, gender identity, race/ethnicity, health insurance, income, education, hormones, surgery, geographic region, HIV status, sex work, substance use, smoking , physical and sexual assault, suicide attempt, data collection mode.

National Transgender Discrimination Survey (NTDS): history of jail/prison 19.3% (n=748)

All RRs p<0.05

Pe

rce

nt (%

)

42


0

5

10

15

20

25

30

35

40

45

50

Black Non-Hispanic

NativeAmerican/

AlaskanNative Non-

Hispanic



PhysicalAssault

SexualAssault




All RRs p<0.05

Pe

rce

nt (%

)

43



0

5

10

15

20

25

30

35

40

45

50

Black Non-Hispanic

NativeAmerican/

AlaskanNative Non-

Hispanic



PhysicalAssault

SexualAssault




All RRs p<0.05

Pe

rce

nt (%

)

44


HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

45




Sexual Networks and Partners:Transgender Youth (n=145)

TFn=63

TMn=82

p-value

Mean Age(SD)

19.4 (3.2)

20.5 (2.6)

0.02

People of Color 52.4% 15.8% <0.0001

HIV Infection 7.9% 2.4% 0.13

Condomless Anal and/or Vaginal Sex 52.4% 43.9% 0.31

Casual Sex Partner 69.8% 42.7% 0.001

Main/Primary Sex Partner 25.4% 48.8% 0.004

Sex Work 33.3% 1.2% <0.0001

Depression 42.9% 54.9% 0.15

Current Alcohol Use 50.8% 58.5% 0.35

Current Drug Use 39.7% 32.9% 0.40

Unstably/Marginally Housed 25.4% 13.45 0.07

Reisner, Vetters, et al. AIDS Care, 2015

Bold indicates statistical significance. Reported p-values are from Fisher’s exact tests where cell sizes were small.

TF=Trans Feminine, TM=Trans Masculine

46

Sexual Networks and Partners:Transgender Youth (n=145)

TFn=63

TMn=82

p-value

Mean Age(SD)

19.4 (3.2)

20.5 (2.6)

0.02

People of Color 52.4% 15.8% <0.0001

HIV Infection 7.9% 2.4% 0.13

Condomless Anal and/or Vaginal Sex 52.4% 43.9% 0.31

Casual Sex Partner 69.8% 42.7% 0.001

Main/Primary Sex Partner 25.4% 48.8% 0.004

Sex Work 33.3% 1.2% <0.0001

Depression 42.9% 54.9% 0.15

Current Alcohol Use 50.8% 58.5% 0.35

Current Drug Use 39.7% 32.9% 0.40

Unstably/Marginally Housed 25.4% 13.45 0.07

Reisner, Vetters, et al. AIDS Care, 2015

Bold indicates statistical significance. Reported p-values are from Fisher’s exact tests where cell sizes were small.

TF=Trans Feminine, TM=Trans Masculine

Adjusted Models

Outcome:Condomless Sex

TM Youth+Casual Sex Partner3.06 increase in odds (p=0.03)

TF Youth++Main/Primary Sex Partner 6.76 increase in odds (p=0.01)

47

HIV


Substance Use

Incarceration

Situated

Vulnerabilities

Sexual Networks

Homelessness


Violence

48

Human DevelopmentTime - Lifecourse

Recalled Developmental Trajectories

Cite: Reisner & Bradford. Recalled transgender developmental trajectories. Manuscript in prep.

11.1

14.3

17.5

19.6

21.922.8

29.0

37.1

Becameaware

transgender

Forced orunwanted sex

First suicideattempt

Physicallyattacked

Tobaccoproblem

Drinkingproblem

Soughtgender

transition

Current age

Me

an A

ge in

Ye

ars

Total Sample

The Virginia Transgender Health Initiative Study (THIS)

n=350

49


Cite: Reisner & Bradford. Recalled transgender developmental trajectories. Manuscript in prep.

11.1

14.3

17.5

19.6

21.922.8

29.0

37.1

Becameaware

transgender



Physicallyattacked

Tobaccoproblem

Drinkingproblem

Soughtgender

transition

Current age

Me

an A

ge in

Ye

ars

Total Sample


n=350

50


ns 1.83* 1.90* ns ns 1.92* 2.85** 7.09**

11.2

15.6

18.320.7

22.1

24.5

30.4

40.4

10.8

12.7

16.417.9

21.8 21.3

25.6

30.9

Becameaware

transgender



Physicallyattacked

Tobaccoproblem

Drinkingproblem

Soughtgender

transition

Current age

Mea

n A

ge in

Yea

rsMTF FTM


n=229 n=121

Longitudinal Models: *p<0.05

**p<0.01 ns = not significant

ns 1.83* 1.90* ns ns 1.92* 2.85**

51

ns 1.83* 1.90* ns ns 1.92* 2.85** 7.09**

11.2

15.6

18.320.7

22.1

24.5

30.4

40.4

10.8

12.7

16.417.9

21.8 21.3

25.6

30.9

Becameaware

transgender



Physicallyattacked

Tobaccoproblem

Drinkingproblem

Soughtgender

transition

Current age

Mea

n A

ge in

Yea

rsMTF FTM


n=229 n=121

Longitudinal Models: *p<0.05

**p<0.01 ns = not significant

ns 1.83* 1.90* ns ns 1.92* 2.85**


52

Overview





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Cite: Reisner, Keatley J, Baral S, Villayzan J, Mothopeng T, van der Merwe LL, Hosie A, Chung C. Transgender community voices: A participatory population perspective. Lancet 2016; 388(10042): 327-330.

Work “with” not “on” transgender communities

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Gender Affirming Clinical and Public Health Model

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456472

http://fenwayhealth.org/the-fenway-institute/

55

Trans Masculine Sexual Health Collaborative

Mixed-methods biobehavioralstudy

Assess feasibility and acceptability of self- vs provider-collection methods for cervical cancer screening

N=150 female-to-male trans masculine adults

Ages 21-64 years; have a cervix; sexually active in last 36 months

http://www.transmaschealth.org/

PCORI PI: Reisner

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Project LifeSkills RCT to test the efficacy of a group-based

empowerment HIV prevention intervention to reduce HIV sexual risk in young transgender women (YTW)

300 YTW ages 16-29 years (Boston & Chicago)

49% Black, 12% Latina, 25% White, 14% other

At enrollment, 22% of participants were HIV-infected (3% previously undiagnosed)

Interim analysis with >90% of visits completed >20% difference in reduction in CS acts (vaginal and

anal) from baseline Statistically significant 12-month arm x time

interaction (F(3,447) = 12.29, p<0.0001)

www.projectlifeskills.org

NIMH R01 MH09432304MPI: Garofalo & MimiagaCo-I: Kuhns & Reisner

57

Feminas Gender-Affirmative Transgender Care to Improve the HIV

Treatment Cascade in Lima, Peru

Aim 1: Formative research Focus groups 48 TW and 19 providers

Aim 2: Interventional study 220 TW (200 completers across 12-mo f/u) Hormones and wrap-around HIV services + peer health navigation Outcomes: HIV testing, linkage to care, viral suppression

Aim 3: Dissemination Community and replication

amfAR Peru PI: LlamaUS MPIs: Mayer & Reisner

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UNICXS

Anti-violence reporting and response network for transgender people in Peru

Adapt components of Fenway’s Violence Recovery Program (VRP)

Increase capacity of Peruvian partners to respond to pervasive violence faced by transgender people

US PI: Reisner Peru PI: Silva-Santisteban

59

Based on feedback that transgender individuals might be denied the right to vote using their DNI, the UNICXS team met with members of the legal network who identified 3 key pieces of advice for people who face this scenario.

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The Way Forward

Address broader social contexts of transgender health

Increase capacity to provide primary care

Improve delivery of gender affirmative care

Decrease barriers to access and utilization of services

Integrate health and human rights approaches

Engage transgender people

Build on community resiliencies

Promote strengths-based efforts

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“Despite substantial gaps in empirical research, there are sufficient actionable data … surrounding health risks and

resiliencies for transgender people that need interventions.”

Contact:[email protected]

Global health burden and needs of transgender populations: a review.Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R,

Baral SD. Lancet. 2016; 388(10042):412-436. pii: S0140-6736(16)00684-X. doi: 10.1016/S0140-6736(16)00684-X.


63

http://www.ncbi.nlm.nih.gov/pubmed/27323919

Please cite this presentation as follows:

Reisner, S.L. Gender Affirmative Health Care: Terminology, Demographics, and Epidemiology. Sept 23, 2016. Advancing Excellence in Transgender Health, Fenway Health, Boston, MA

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