Walter Bockting

A Comparison of Mental Health, Substance Use, and Sexual Risk Behaviors Between Rural and Non-Rural Transgender Persons

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.

Recommendations for Internet-Based Qualitative Health Research With Hard-to-Reach Populations

Researchers new to online qualitative health research frequently have questions about how to transfer knowledge of offline data collection to an online environment. In this article, we present best-practice guidelines derived from the literature and our experience to help researchers determine if an online qualitative study design is appropriate for their research project and, if so, when to begin data collection with a hard-to-reach population. Researchers should reflect on administrative, population, and data collection considerations when deciding between online and offline data collection. Decisions must be made regarding whether to conduct interviews or focus groups, to collect data using asynchronous or synchronous methods, and to use only text or to incorporate visual media. Researchers should also reflect on human subjects, recruitment, research instrumentation, additional data collection, and public relations considerations when writing protocols to guide the research team’s response to various situations. Our recommendations direct researchers’ reflection on these considerations.

Advancing methods for US transgender health research

Purpose of reviewThis article describes methodological challenges, gaps, and opportunities in US transgender health research. Recent findingsLack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities. SummaryTransgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

Adult development and quality of life of transgender and gender nonconforming people.

Purpose of reviewResearch on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. The present review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research. Recent findingsPervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and well-being. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. Although there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking. SummaryGreater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

HIV Risk Behaviors in the U.S. Transgender Population: Prevalence and Predictors in a Large Internet Sample

To study the influence of gender on HIV risk, a sample of the U.S. transgender population (N = 1,229) was recruited via the Internet. HIV risk and prevalence were lower than reported in prior studies of localized, urban samples but higher than the overall U.S. population. Findings suggest that gender nonconformity alone does not itself result in markedly higher HIV risk. Sex with nontransgender men emerged as the strongest independent predictor of unsafe sex for both male-to-female (MtF) and female-to-male (FtM) participants. These sexual relationships constitute a process that may either affirm or problematize gender identity and sexual orientation, with different emphases for MtFs and FtMs, respectively.

Gender Abuse and Incident HIV/STI Among Transgender Women in New York City: Buffering Effect of Involvement in a Transgender Community

AbstractIn a 3xa0year prospective study of 230 transgender women from the New York City Area, we further examined associations of gender-related abuse with HIV sexual risk behavior and incident HIV/STI, focusing here and the extent to which these associations are buffered by involvement in a transgender community. Largely consistent with the prior study, gender abuse was longitudinally associated with unprotected receptive anal intercourse (URAI) with casual and commercial sex partners, and the presumed biological outcome of this behavioral risk, new cases of HIV/STI. Both of these associations, gender abuse with URAI and HIV/STI, were significantly buffered by transgender community involvement (interaction effects). However, independent of these interaction effects, transgender community involvement was also positively associated with URAI and HIV/STI (direct effects). HIV prevention in this population should emphasize the benefits of interactions with transgender peers while also emphasizing the importance of resisting normative permission for HIV risk behavior from these same peers.n

Nonsuicidal self‐injury among lesbian, gay, bisexual and transgender populations: an integrative review

AIMS AND OBJECTIVESnTo conduct an integrative review of nonsuicidal self-injury among lesbian, gay, bisexual and transgender populations to better understand the prevalence; to identify the lesbian, gay, bisexual and transgender subgroups at increased risk for nonsuicidal self-injury; and to examine the risk factors associated with nonsuicidal self-injury among lesbian, gay, bisexual and transgender populations.nnnBACKGROUNDnNonsuicidal self-injury, defined as intentional injury to the bodys surface without intent to die, is a significant mental health concern among adolescents and adults. Mental health disparities in lesbian, gay, bisexual and transgender populations, including anxiety, depression and suicidality, have been documented in the scientific literature with little focus on findings about nonsuicidal self-injury.nnnDESIGNnIntegrative literature review of published quantitative and qualitative empirical research.nnnMETHODSnA literature search of 11 on-line databases was conducted of articles published through April 2015. Keywords were used to identify articles about lesbian, gay, bisexual and transgender populations and nonsuicidal self-injury.nnnRESULTSnAfter screening by title, abstract and full text, 26 articles were included in this review. The literature synthesised demonstrates a consistent pattern of increased prevalence of nonsuicidal self-injury among sexual and gender minority populations compared with heterosexual peers. This body of literature indicates which subgroups of the lesbian, gay, bisexual and transgender populations appear to be at increased risk for nonsuicidal self-injury and which specific factors contributing to vulnerability to nonsuicidal self-injury among these populations.nnnCONCLUSIONSnLesbian, gay, bisexual and transgender populations are at higher risk for nonsuicidal self-injury compared with the general population. Lesbian, gay, bisexual and transgender-specific and general risk factors appear to contribute to this heightened vulnerability.nnnRELEVANCE TO CLINICAL PRACTICEnClinical nurses should screen for nonsuicidal self-injury and for sexual and gender minority identity in all of their patients. Comprehensive assessment of lesbian, gay, bisexual and transgender patients presenting with nonsuicidal self-injury may lead to identification of risk factors that can be addressed through nursing interventions. Nurse researchers and clinicians should take an active role in developing and implementing evidenced-based tailored interventions to reduce the higher vulnerability to nonsuicidal self-injury among lesbian, gay, bisexual and transgender populations.

Patient perspectives on answering questions about sexual orientation and gender identity: an integrative review

AIMS AND OBJECTIVESnTo examine patients perceptions of being asked about their sexual orientation and gender identity in the healthcare setting.nnnBACKGROUNDnHealth disparities exist in the lesbian, gay, bisexual and transgender population, but further research is needed to better understand these disparities. To address this issue, experts recommend the routine collection of sexual orientation and gender identity data in health care. Nurses on the front line of patient care play a key role in the collection of these data. However, to enable nurses to conduct such assessments it is important to understand the perspective of the patients on being asked about their sexual orientation and gender identity in a healthcare setting.nnnDESIGNnAn integrative review was conducted using the methodology proposed by Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546).nnnMETHODSnSix electronic databases were searched, and two reviewers independently reviewed papers for inclusion. Papers were included if they were empirical studies, peer-reviewed papers or reports, assessing patient perspectives on discussing sexual orientation and gender identity in the healthcare setting.nnnRESULTSnTwenty-one relevant studies that met the inclusion criteria were identified. A majority of the studies indicated patients willingness to respond to, and a perceived importance of, questions about sexual orientation and gender identity. However, fears of homophobia and negative consequences hindered willingness to disclose this information.nnnCONCLUSIONSnThis review indicates that in most cases patients are willing to answer routine questions about their sexual orientation in the healthcare setting and perceive them as important questions to ask.nnnRELEVANCE TO CLINICAL PRACTICEnThe findings of this review have implications for nurses looking to incorporate questions about sexual orientation into their routine patient assessment. The findings indicate that care providers need to be mindful of heteronormative assumptions and take steps to ensure they are knowledgeable about lesbian, gay, bisexual and transgender health.

The Impact of Stigma on Transgender Identity Development and Mental Health

The existence of transgender and gender-nonconforming people has been documented throughout history and across cultures. In the twentieth century, transgender expression became medicalized and sex reassignment became available, initially enforcing a binary understanding of sex/gender as either male or female, man or woman, and masculine or feminine. The goal was to adjust and live either as a man or as a woman, evading the social stigma attached to gender nonconformity. However, it quickly became clear that stigma was pervasive and continued, even for those who fully transitioned to living as a member of the other sex. Transsexual and transgender individuals found support among each other, affirmed their specific identity and experience, and advocated for their rights. Since the 1990s, the paradigm shifted toward (re)discovery of a spectrum of gender diversity. Transgender is now an identity, no longer a disorder, and identifying as such is for many an important part of their coming-out process to affirm their differentness, find belonging in a community of peers, challenge stigma, and advocate for inclusion, respect, and acceptance. Research has established the association between discrimination and psychological distress, with family support, identity pride, and particularly peer support serving as protective factors. What is needed is a greater understanding of the mechanism of stigma, both for the minority population and for the sociocultural context in which stigma is produced and perpetuated, to inform policies promoting transgender rights and resilience.

Special-“T” Training: Extended Follow-up Results from a Residency-Wide Professionalism Workshop on Transgender Health

ObjectiveTransgender people face unique challenges when accessing health care, including stigma and discrimination. Most residency programs devote little time to this marginalized population.MethodsThe authors developed a 90-min workshop to enhance residents’ ability to empathize with and professionally treat transgender patients. Attendees completed pre-, post, and 90-day follow-up surveys to assess perceived empathy, knowledge, comfort, interview skill, and motivation for future learning.ResultsTwenty-two residents (64.7xa0%) completed pre- and post-workshop surveys; 90.9xa0% of these completed the 90-day follow-up. Compared to baseline, there were statistically significant post-workshop increases in perceived empathy, knowledge, comfort, and motivation for future learning. However on 90-day follow-up, there were no statistically significant differences across any of the five domains, compared to baseline.ConclusionsThis workshop produced significant short-term increases in resident professionalism toward transgender patients. However, extended follow-up results highlight the limitations of one-time interventions and call for recurrent programming to yield durable improvements.