Connecting the Dots: Examining Transgender Women’s Utilization of Transition-Related Medical Care and Associations with Mental Health, Substance Use, and HIV

Abstract

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.

HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil

“…Gender affirming care includes the correct use of pronouns and provision of hormone therapy, among others, and may be offered even in settings without referral centres specialized in transgender healthcare. Such services have been shown to reduce mental health risks [22,23] and improve quality of life for transgender people [24]. In the absence of the ability of the public health system to end systemic discrimination towards transwomen, offering hormones and providing an environment where transwomen’s gender identity is respected may be one way to improve linkage to care and increase HIV viral suppression among transwomen.…”

Substance use and treatment of substance use disorders in a community sample of transgender adults

“…All models were adjusted for survey mode and included the following variables, which were selected based on prior research indicating that comparable factors are predictive of substance use in other samples, excepting non-binary gender identity, which was included as a variable of interest due to the absence of prior research assessing its relationship to substance use: age (continuous; Kessler et al, 2005), higher educational attainment (yes/no; Gfroerer et al, 1997), higher income (yes/no; Bassuk et al, 1998), people of color (yes/no; Wallace and Muroff, 2002), MTF spectrum (yes/no; Herbst et al, 2008), non-binary gender (yes/no; Flentje et al, 2015), medical gender affirmation (yes/no; Wilson et al, 2015), lifetime intimate partner violence (yes/no; Reisner et al, 2013), lifetime PTSD diagnosis (yes/no; Jacobsen et al, 2001; Rowe et al, 2015), past 7-day clinically significant depression (yes/no; Davis et al, 2008), current mental health treatment (yes/no; Kessler et al, 1996), inability to access gender-transition care in past 12 months (yes/no; Wilson et al, 2015), public accommodations discrimination in past 12 months (yes/no; Nuttbrock et al, 2014b), past 12-month unstable housing (yes/no; Bassuk et al, 1998), and past 12-month sex work (yes/no; Rekart, 2005). Models were adjusted for recent substance use, as appropriate.…”

“…Nevertheless, transgender individuals face numerous barriers to receiving appropriate gender-affirming health care (Operario and Nemoto, 2010), including a lack of both competent providers and insurance coverage (Operario and Nemoto, 2010; Sanchez et al, 2009; Spicer, 2010; Stroumsa, 2014). The psychological stress of health care access disparities faced by transgender people is believed to contribute to worse mental health (Poteat et al, 2013), including disproportionate substance use as a coping strategy (Wilson et al, 2015). A recent study examined the relationship of gender-affirming medical services to recent alcohol and drug use among transgender women (Wilson et al, 2015), however, the sample did not include transgender men, and SUD treatment utilization was not assessed.…”

“…The psychological stress of health care access disparities faced by transgender people is believed to contribute to worse mental health (Poteat et al, 2013), including disproportionate substance use as a coping strategy (Wilson et al, 2015). A recent study examined the relationship of gender-affirming medical services to recent alcohol and drug use among transgender women (Wilson et al, 2015), however, the sample did not include transgender men, and SUD treatment utilization was not assessed. Thus research exploring the specific relationship of cross-sex hormone therapy and/or gender-affirming surgery to substance use and SUD treatment utilization among diverse groups of transgender people is warranted.…”

Documentation Status as a Contextual Determinant of HIV Risk Among Young Transgender Latinas

“…14,20 Furthermore, finding gender affirmation in a sexual partner is very important for transgender women's mental health. 21 Although studies have included African American and Latina TW in their samples, 2,15,22,23 few have assessed contextual determinants of HIV specific to these groups. 24,25 Documentation status (legal authorization to live in the United States) is sometimes mentioned as a limitation for recruiting or retaining immigrant (noncitizen who lives in the United States) Latino/a sexual minorities in prevention and treatment, [26][27][28][29] but not as a contextual determinant of the HIV-related syndemic among transgender immigrant Latinas.…”