Jeffrey Becker

Psychiatric Impact of Gender-Related Abuse Across the Life Course of Male-to-Female Transgender Persons

The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19–39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40–59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.

Sexual orientation data collection and progress toward Healthy People 2010

Without scientifically obtained data and published reports, it is difficult to raise awareness and acquire adequate resources to address the health concerns of lesbian, gay, and bisexual Americans. The Department of Health and Human Services must recognize gaps in its information systems regarding sexual orientation data and take immediate steps to monitor and eliminate health disparities as delineated in Healthy People 2010. A paper supported by funding from the Office of the Assistant Secretary for Planning and Evaluation explores these concerns and suggests that the department (1) create work groups to examine the collection of sexual orientation data; (2) create a set of guiding principles to govern the process of selecting standard definitions and measures; (3) recognize that racial/ethnic, immigrant-status, age, socioeconomic, and geographic differences must be taken into account when standard measures of sexual orientation are selected; (4) select a minimum set of standard sexual orientation measures; and (5) develop a long-range strategic plan for the collection of sexual orientation data.

Don't Wanna Go Through That Madness No More: Quality of Life Satisfaction as Predictor of Sustained Remission from Illicit Drug Misuse

Individuals who have developed a clinical dependence on drugs and/or alcohol often report that they sought help because they were “sick and tired of being sick and tired.” Quality of life (QOL) remains the missing measurement in the addictions arena. The few studies conducted to date show that QOL is typically poor during active addiction and improves as a function of remission. An intriguing question bears on the role of QOL in subsequent remission status. Reasoning that higher life satisfaction may “increase the price” of future use and thus enhance the likelihood of sustained remission, this exploratory study tests the hypotheses that QOL satisfaction prospectively predicts sustained remission, and that motivational constructs mediate the association. Inner city residents (N = 289, 53.6% male, mean age 43) remitting from chronic and severe histories of dependence to crack and/or heroin were interviewed three times at yearly interval beginning in April 2003. Logistic regression findings generally support our hypotheses: Controlling for other relevant variables, baseline life satisfaction predicted remission status 1 and 2 years later and the association was partially mediated by motivation (commitment to abstinence) although the indirect effect did not reach statistical significance. Findings underline the importance of examining the role of QOL satisfaction in remission processes. Limitations of this exploratory study are discussed, including the use of a single-item global life satisfaction rating; suggestions for future studies are discussed including the need to embrace QOL as a bona fide clinical outcome and to use comprehensive standardized QOL measures that speak to individual dimensions of functioning. Implications are noted, especially the need for the addiction field to continue moving away from the pathology-focused model of care toward a broader model that embraces multiple dimensions of positive health as a key outcome.

Gender Abuse, Depressive Symptoms, and HIV and Other Sexually Transmitted Infections Among Male-to-Female Transgender Persons: A Three-Year Prospective Study

OBJECTIVES We examined gender abuse and depressive symptoms as risk factors for HIV and other sexually transmitted infections (HIV/STI) among male-to-female transgender persons (MTFs). METHODS We conducted a 3-year prospective study of factors associated with incident HIV, syphilis, hepatitis B, chlamydia, and gonorrhea among 230 MTFs from the New York Metropolitan Area. Statistical techniques included Cox proportional hazards analysis with time varying covariates. RESULTS Among younger MTFs (aged 19-30 years), gender abuse predicted depressive symptoms (Center for Epidemiologic Studies Depression score ≥ 20), and gender abuse combined with depressive symptoms predicted both high-risk sexual behavior (unprotected receptive anal intercourse) and incident HIV/STI. These associations were independent of socioeconomic status, ethnicity, sexual orientation, hormone therapy, and sexual reassignment surgery. CONCLUSIONS Gender abuse is a fundamental distal risk factor for HIV/STI among younger MTFs. Interventions for younger MTFs are needed to reduce the psychological impact of gender abuse and limit the effects of this abuse on high-risk sexual behavior. Age differences in the impact of gender abuse on HIV/STI suggest the efficacy of peer-based interventions in which older MTFs teach their younger counterparts how to cope with this abuse.

Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons.

Objectives:To describe and evaluate risk factors for HIV/sexually transmitted infections (STIs) among male-to-female (MTF) transgender persons. Methods:Using the life chart interview, potential lifetime risk factors for HIV/STIs among MTFs were measured and evaluated in conjunction with lifetime exposures for HIV, syphilis, hepatitis B, and hepatitis C. The participants were 517 MTFs between the ages of 19 and 59 years from the New York metropolitan area. Results:HIV/STIs were low among white Americans and very high among Hispanics and African Americans. In the latter groups, HIV and hepatitis B were associated with an androphilic sexual orientation, lifetime number of commercial sex partners (sex work), and the social expression of transgender identity; syphilis was associated with lifetime number of casual sex partners; and hepatitis C was associated with injection drug use, unemployment, and social expression of transgender identity. In multivariate models, the social expression of transgender identity was the strongest and most consistent predictor of HIV/STIs. Consistent with their lower levels of infections, white Americans reported significantly lower levels of the risk factors found to be predictive of HIV/STI among Hispanics and African Americans. Conclusions:HIV/STI prevention in this population should be targeted at Hispanic and African Americans. Prevention programs should incorporate multiple components designed to address the diverse issues confronting ethnic minority transgender persons, with an emphasis on the social expression of transgender identity.

Gender Abuse and Major Depression Among Transgender Women: A Prospective Study of Vulnerability and Resilience

OBJECTIVES We examined the social and interpersonal context of gender abuse and its effects on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depression among transgender women. METHODS We conducted a 3-year prospective study (2004-2007) among 230 transgender women aged 19 to 59 years from the New York City Metropolitan Area. Statistical techniques included generalized estimating equations (logistic regression). RESULTS We observed significant associations of psychological and physical gender abuse with major depression during follow-up. New or persistent experiences of both types of abuse were associated with 4- to 7-fold increases in the likelihood of incident major depression. Employment, transgender presentation, sex work, and hormone therapy correlated across time with psychological abuse; the latter 2 variables correlated with physical abuse. The association of psychological abuse with depression was stronger among younger than among older transgender women. CONCLUSIONS Psychological and physical gender abuse is endemic in this population and may result from occupational success and attempts to affirm gender identity. Both types of abuse have serious mental health consequences in the form of major depression. Older transgender women have apparently developed some degree of resilience to psychological gender abuse.

Gender identity affirmation among male-to-female transgender persons: a life course analysis across types of relationships and cultural/lifestyle factors

Disclosures of a transgender identity to others, and responses from others allowing for desired gender role behavior, are defining events for male-to-female (MTF) transgender persons. This study systematically examined these interpersonal acts of gender identity affirmation among 571 MTF transgender persons from New York City. Using the Life Chart Interview, biographical information about gender identity disclosure to others and desired gender role casting from others was obtained across stages of the life course (early adolescence, late adolescence, early adulthood, young adulthood and middle age) and types of relationships (parents, siblings, sexual partners, friends, fellow students and co-workers). Summaries of gender identity disclosure and gender role casting were then computed across the life course and relationships and associated with sexual orientation, ethnicity and sex work history (cultural/lifestyle factors). The two aspects of gender identity affirmation were, predictably, more likely in achieved (i.e. friends) as compared to ascribed (i.e. parents) relationships. Younger respondents (age 19–39) were generally more likely to report gender identity disclosure and desired gender role casting. Strong and highly significant differences were observed across cultural/lifestyle factors. Implications of these findings for the mental health of MTF transgender persons, and mental health therapy, are discussed.

A Further Assessment of Blanchard's Typology of Homosexual Versus Non-Homosexual or Autogynephilic Gender Dysphoria

In a series of important but now highly controversial articles, Blanchard examined associations of sexual orientation and transvestic fetishism among male-to-female (MTF) transgender persons in Toronto, Canada. Transvestic fetishism was rare among the homosexuals but prevalent among the non-homosexuals. Subtypes of non-homosexual MTFs (heterosexual, bisexual, and asexual) were consistently high with regard to transvestic fetishism. Non-linear associations of a continuous measurement of sexual attraction to women (gynephilia) and transvestic fetishism were interpreted in terms of an etiological hypothesis in which transvestic fetishism interferes with the early development of heterosexuality. Blanchard concluded that homosexual versus non-homosexual sexual orientation is a dominant and etiologically significant axis for evaluating and understanding this population. We further assessed these findings among 571 MTFs from the New York City metropolitan area. Using the Life Chart Interview, multiple measurements of transvestic fetishism were obtained and classified as lifetime, lifecourse persistent, adolescent limited, and adult onset. Large (but not deterministic) differences in lifetime, lifecourse persistent, and adolescent limited transvestic fetishism were found between the homosexuals and non-homosexuals. Contrary to Blanchard, differences in transvestic fetishism were observed across subtypes of the non-homosexuals, and linear (not curvilinear) associations were found along a continuous measurement of gynephilia and transvestic fetishism. Age and ethnicity, in addition to sexual orientation, were found to be statistically significant predictors of transvestic fetishism. The clinical, etiological, and sociopolitical implications of these findings are discussed.

Gender Abuse, Depressive Symptoms, and Substance Use Among Transgender Women: A 3-Year Prospective Study

OBJECTIVES We examined the effects of gender abuse (enacted stigma), depressive symptoms, and demographic, economic, and lifestyle factors on substance use among transgender women. METHODS We conducted a 3-year prospective study (December 2004 to September 2007) of 230 transgender women aged 19 to 59 years from the New York Metropolitan Area. Statistical techniques included generalized estimating equations with logistic and linear regression links. RESULTS Six-month prevalence of any substance use at baseline was 76.2%. Across assessment points, gender abuse was associated with alcohol, cannabis, cocaine, or any substance use during the previous 6 months, the number of days these substances were used during the previous month, and the number of substances used. Additional modeling associated changes in gender abuse with changes in substance use across time. Associations of gender abuse and substance use were mediated 55% by depressive symptoms. Positive associations of employment income, sex work, transgender identity, and hormone therapy with substance use were mediated 19% to 42% by gender abuse. CONCLUSIONS Gender abuse, in conjunction with depressive symptoms, is a pervasive and moderately strong risk factor for substance use among transgender women. Improved substance abuse treatment is sorely needed for this population.

Gender Identity Conflict/Affirmation and Major Depression Across the Life Course of Transgender Women

ABSTRACT Using the Life Chart Interview, a validated instrument for the collection of biographical data, lifetime information about transgender experiences was collected in a community-based sample of 571 transgender women from the New York metropolitan area. Disclosures of transgender identity in different types of relationships, responses of relationship partners indicative of gender identity conflict or affirmation, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression were assessed within and across five stages of the life course. Gender identity conflict/affirmation was associated with major depression within stages of the life course (contemporaneous analysis) and predictive of changes in major depression across stages of the life course (lagged analysis).