Purpose: To identify geographic and individual-level factors associated with healthcare access among transgender people in the United States. Methods: Multilevel analyses were conducted to investigate lifetime healthcare refusal using national data from 5831 U.S. transgender adults. Hierarchical generalized linear models examined associations between individual (age, gender, race, income, insurance, and healthcare avoidance) and state-level factors (percent voting Republican, percent same-sex couple households, income inequality, and transgender protective laws) and lifetime refusal of care. Results: Results show that individual-level factors (being older; trans feminine; Native American, multiracial, or other racial/ethnic minority; having low income; and avoiding care due to discrimination) are positively associated with care refusal (all P-values <0.05). Adjusting for individual-level factors, variation was observed across U.S. states, with a greater proportion of states in the Southern and Western United States with transgender residents at increased odds of experiencing care refusal, relative to other regions of the United States. When adjusting for state-level factors, the percentage of the state population voting Republican was positively associated with care refusal among the transgender adults sampled (P < 0.01). Conclusion: Transgender adults surveyed reported differential access to healthcare by geographic region. Identifying geographic and individual-level factors associated with healthcare barriers allows for the development of targeted educational and policy interventions to improve healthcare access for transgender people most in need of services.

There is a growing interest in HIV infection and sexually transmitted infection (STI) disease burden and risk among transgender people globally; however, the majority of work has been conducted with male-to-female (MTF) transgender populations. This research synthesis comprehensively reviews HIV and STI research in female-to-male (FTM) transgender adults. A paucity of research exists about HIV and STIs in FTMs. Only 25 peer-reviewed papers (18 quantitative, 7 qualitative) and 11 ‘grey literature’ reports were identified, most in the U.S. or Canada, that include data identifying HIV and STI risks in FTMs (five with fully laboratory-confirmed HIV and/or STIs, and five with partial laboratory confirmation). Little is known about the sexual and drug use risk behaviors contributing to HIV and STIs in FTMs. Future directions are suggested, including the need for routine surveillance and monitoring of HIV and STIs globally by transgender identity, more standardized sexual risk assessment measures, targeted data collection in lower and middle income countries, and explicit consideration of the rationale for inclusion/exclusion of FTMs in category-based prevention approaches with MSM and transgender people. Implications for research, policy, programming, and interventions are discussed, including the need to address diverse sexual identities, attractions, and behaviors and engage local FTM communities.

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Extracurricular groups can promote healthy development, yet the literature has given limited attention to indirect associations between extracurricular involvement and mental health or to sexual and gender minority youth. Among 580 youth (Mage = 15.59, range = 10–20 years) and adult advisors in 38 Gender‐Sexuality Alliances (GSAs), multilevel structural equation models showed that greater engagement in GSAs over the school year predicted increased perceived peer validation, self‐efficacy to promote social justice, and hope (baseline adjusted). Through increased hope, greater engagement indirectly predicted reduced depressive and anxiety symptoms at the year’s end (baseline adjusted). GSAs whose members had more mental health discussions and more meetings reported reduced mental health concerns. Findings suggest how groups addressing issues of equity and justice improve members’ health.

BACKGROUND: Transgender and gender nonbinary adolescents experience high rates of peer victimization, but the prevalence of sexual assault in this population has not been established. Some schools restrict transgender and nonbinary students from using restrooms and locker rooms that match their gender identity, with unknown effects on sexual assault risk. We tested whether these restrictions were associated with the 12-month prevalence of sexual assault victimization. METHODS: Survey responses were analyzed from 3673 transgender and nonbinary US adolescents in grades 7 through 12 who participated in the cross-sectional 2017 LGBTQ Teen Study. We estimated the association between school restroom and locker room restrictions and sexual assault, adjusting for potential social and behavioral confounders, using logistic regression. We also tested potential mediators. RESULTS: The 12-month prevalence of sexual assault was 26.5% among transgender boys, 27.0% among nonbinary youth assigned female at birth, 18.5% among transgender girls, and 17.6% among nonbinary youth assigned male at birth. Youth whose restroom and locker room use was restricted were more likely to experience sexual assault compared with those without restrictions, with risk ratios of 1.26 (95% confidence interval [CI]: 1.02–1.52) in transgender boys, 1.42 (95% CI: 1.10–1.78) in nonbinary youth assigned female at birth, and 2.49 (95% CI: 1.11–4.28) in transgender girls. Restrictions were not associated with sexual assault among nonbinary youth assigned male at birth. CONCLUSIONS: Pediatricians should be aware that sexual assault is highly prevalent in transgender and nonbinary youth and that restrictive school restroom and locker room policies may be associated with risk.