Sean Arayasirikul

Connecting the dots: examining transgender women's utilization of transition-related medical care and associations with mental health, substance use, and HIV.

Findings on access to general healthcare for transgender people have emerged, but little is known about access to transition-related medical care for transwomen (i.e., hormones, breast augmentation, and genital surgery). Transgender women have low access to general medical care and are disproportionately at risk for substance use, mental illness, and HIV. We conducted an analysis to determine if utilization of transition-related medical care is a protective factor for health risks to transgender women and to investigate if care differs by important demographic factors and HIV status. A secondary analysis was conducted using data from a 2010 HIV surveillance study using respondent-driven sampling to recruit 314 transwomen in San Francisco. Survey-corrected logistic regression models were used to estimate odds ratios for six psychosocial health problems—binge drinking, injection drug use, anxiety, depression, suicidal ideation, and high-risk intercourse—comparing various levels of utilization of transition-related medical care. Odds ratios were also calculated to determine if utilization of transition-related medical care was related to less overlap of risk domains. We found that Latina and African American transwomen had significantly lower estimated utilization of breast augmentation and genital surgery, as did transwomen who identified as transgender rather than female. Overall, utilization of transition-related medical care was associated with significantly lower estimated odds of suicidal ideation, binge drinking, and non-injection drug use. Findings suggest that utilization of transition-related medical care may reduce risk for mental health problems, especially suicidal ideation, and substance use among transwomen. Yet, important racial/ethnic and gender identity disparities in utilization of transition-related medical care need to be addressed.

Differential HIV Risk for Racial/Ethnic Minority Trans*female Youths and Socioeconomic Disparities in Housing, Residential Stability, and Education

OBJECTIVES We examined HIV prevalence and risk behaviors of 282 trans*female youths aged 16 to 24 years participating in the San Francisco Bay Area, California, SHINE study from 2012 to 2013 to determine differences between racial/ethnic minority and White youths. METHODS We conducted the χ(2) test to determine distributional differences between racial/ethnic minority and White participants in sociodemographic factors, HIV-related risk behaviors, and syndemic factors. RESULTS Of the trans*female youths, 4.8% were HIV positive. Racial/ethnic minority and White trans*female youths differed significantly in gender identity and sexual orientation. Racial/ethnic minority youths also had significantly lower educational attainment, were less likely to have lived with their parents of origin as a child, and were significantly more likely to engage in recent condomless anal intercourse than were Whites. CONCLUSIONS Efforts to assess the impact of multiple-minority stress on racial/minority trans*female youths are needed imminently, and prevention efforts must address macrolevel disparities for trans*female youths, especially those from racial/ethnic minority groups, to reduce these disparities and prevent incident cases of HIV.

Access to HIV Care and Support Services for African American Transwomen Living with HIV

ABSTRACT Low access to HIV care and support has led to survival rates for transwomen that are half that of other populations at risk for HIV. Within the population, HIV disproportionately impacts African American transwomen. Interventions to increase access to HIV care and support are needed to better serve those most affected and vulnerable within the population. We conducted a study of barriers to care and support services for African American transwomen to fill a gap in the literature to improve access for this population. A total of 10 in-depth interviews were conducted with African American transwomen with HIV who lived outside the metro area of San Francisco. Three overarching thematic topics emerged—gender stigma, peer, and institutional distrust—giving insight into African American transwomens barriers to HIV care and support services. A number of factors within these themes impacted access, such as whether organizations offered gender-related care, the geography of organizations as it relates to safe transportation and location, confidentiality and trust of peers and organizations, and trauma. Specific instrumental, institutional, and emotional supports are recommended for increasing access to care and support services for African American transwomen living with HIV.

Types of social support and parental acceptance among transfemale youth and their impact on mental health, sexual debut, history of sex work and condomless anal intercourse

Transfemale youth (TFY) are an underserved and understudied population at risk for numerous poor physical and mental health outcomes, most notably HIV. Research suggests that parental acceptance and social support may serve as protective factors against HIV and other risks for TFY; however, it is unclear whether TFY receive primary social support from parents with or without parental acceptance of their gender identity. This study examines differences in parental acceptance, mental health and the HIV risk factors of history of sex work, age at sexual debut and engagement in condomless anal intercourse between TFY with two types of primary social support – non‐parental primary social support (NPPSS) and parental primary social support (PPSS).

Unevenness in Health at the Intersection of Gender and Sexuality: Sexual Minority Disparities in Alcohol and Drug Use Among Transwomen in the San Francisco Bay Area

ABSTRACT Research on the health of transwomen is largely focused on heterosexual HIV risk. Little is known about the health of sexual minority transwomen. We conducted a secondary cross-sectional analysis of data from a HIV risk and resilience study of transwomen aged 16 to 24 years in the San Francisco Bay Area (N = 259). Prevalence and demographic characteristics of sexual minority transwomen was assessed and logistic regression models were used to examine the relationship between sexual minority status and alcohol and drug use. In logistic regression models, sexual minority transwomen had greater fold odds of heavy episodic drinking and illicit prescription drug use compared to their heterosexual counterparts, controlling for race/ethnicity, age, income, nativity, hormone status, and history of feminization procedures. These results suggest that sexual minority status may be an important social determinant of health among gender minorities. Populations of transwomen are heterogeneous; effective interventions must consider sexual minority status.

A Qualitative Examination of Respondent-Driven Sampling (RDS) Peer Referral Challenges Among Young Transwomen in the San Francisco Bay Area

Background Efforts have focused on developing innovative recruitment strategies to engage the most marginalized of populations in public health research. Respondent-driven sampling (RDS) has been found to be an effective sampling strategy for hard-to-reach, hidden populations. Though studies have documented RDS peer referral as challenging, literature contextualizing these challenges is scant and rarely do they discuss the role of Internet technologies. Objective The objective of the study was to explore reasons for peer referral challenges in a human immunodeficiency virus (HIV) risk and resilience study among a hidden population of youth, specifically, young transwomen. These findings amplify the unique opportunities Internet technologies bring to public health research and methodology. Methods We conducted focused, semistructured, qualitative interviews with 16 young transwomen to investigate the reasons why youth did or did not refer peers to an RDS study for transwomen ages 16-24 in the San Francisco Bay Area. Qualitative interview data were coded and analyzed using grounded theory. Results Participants discussed specific barriers and facilitators related to four factors that include study design, study implementation, community characteristics, and individual characteristics, which contributed to RDS peer referral challenges. Conclusions Our grounded theory analysis identifies important considerations for future RDS studies with hidden youth populations. Exploring research participants’ experiences is integral in strengthening future epidemiologic research efforts that plan to use RDS to sample and estimate the hidden epidemics among at-risk youth and transgender women. Additionally, Internet technologies and Web-based adaptations offer solutions to traditional RDS peer referral challenges, having the potential to increase accessibility and use among hidden youth populations.

Psychosocial predictors of engagement in sexual risk behavior among trans*female youth ages 16 - 24 years in San Francisco.

Background: Trans*female youth (TFY) carry a disproportionate burden of HIV. Few longitudinal studies have analyzed both proximal and upstream predictors of changes in HIV-related risk behaviors for TFY. The aim of the present analysis was to identify psychosocial predictors of changes in sexual risk behavior over time for TFY in the San Francisco Bay Area. Methods: Data come from the SHINE cohort study conducted at the San Francisco Department of Public Health from 2012 to 2014 (n = 263). The relationship between hypothesized psychosocial factors and changes in engagement in condomless receptive anal intercourse over 12-month follow-up was modeled using generalized estimating equations, after adjusting for participant age, race/ethnicity, and education level. Results: TFY who were ever in a serious relationship since identifying as trans* [adjusted odds ratio (aOR) = 1.89, 95% confidence interval (CI): 1.16 to 3.08], those who reported recent crack/cocaine use (aOR = 2.01, 95% CI: 1.05 to 3.85), and those with a monthly income of more than

The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

500 (aOR = 0.55, 95% CI: 0.35 to 0.85) had significantly higher odds of condomless receptive anal intercourse over the 12-month study period compared to TFY without these exposures. Those who reported high exposure to gender-based discrimination had increased adjusted odds of engagement in condomless receptive anal intercourse compared to those who had low exposure over the study period (aOR = 1.70, 95% CI: 1.10 to 2.63). Conclusions: Both proximal and structural factors predicted increased engagement in sexual risk behavior among TFY. Results demonstrate the need for a multilevel approach to HIV prevention strategies for this population.