Sari L. Reisner, ScD Assistant Professor of Pediatrics, Boston Children’s Hospital/Harvard Medical School Assistant Professor of Epidemiology, Harvard T.H. Chan School of Public Health Affiliated Research Scientist, Fenway Health Gender Affirmative Health Care: Terminology, Demographics, and Epidemiology
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Sari L. Reisner, ScDAssistant Professor of Pediatrics, Boston Children’s Hospital/Harvard Medical School
Assistant Professor of Epidemiology, Harvard T.H. Chan School of Public Health
Affiliated Research Scientist, Fenway Health
Gender Affirmative Health Care:
Terminology, Demographics,
and Epidemiology
Continuing Medical Education Disclosure Program Faculty: Sari Reisner, ScD
Current Position: Assistant Professor of Pediatrics, Harvard Medical School; Associate Scientific Researcher, Boston Children’s Hospital
Disclosure: No relevant financial relationships. Presentation does not include discussion of off-label products.
It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staffdisclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potentialconflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interestor who agree to an identified resolution process prior to their participation were involved in this CME activity.
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Overview
Terminology: Sex, Gender, and Transgender
Global Health Burden in Transgender People
Situated Vulnerabilities
Participatory Population Perspective
3
Overview
Terminology: Sex, Gender, and Transgender
Global Health Burden in Transgender People
Situated Vulnerabilities
Participatory Population Perspective
4
Sex and Gender
5
Sex and gender core determinants of health
Sex – biological differences Anatomy, chromosomes, hormones,
genes, etc.
Gender – social and cultural distinctions mapped onto biology Multidimensional
Psychological, social, behavioral
Gender identity, gender expression, gender roles
Transgender
6
Gender identity or expression different than assigned sex at birth Male-to-Female (MTF), transgender women,
transgender girls, trans feminine (TF)
Female-to-Male (FTM), transgender men, transgender boys, trans masculine (TM)
Other diverse genders: genderqueer, nonbinary, bigender, gender expansive
Cultural variations (hijra, waria, travesti, trans)
Gender diversity ≠ pathology Approximately 25 million transgender people
worldwide
Gender Affirmation
Process by which individuals are affirmed in their gender identity or expression
Fenway Health: Trans Health Program Growth, 1997-2015
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N=11 N=41N=116
N=366
N=879
N=1208
N=1456
N=2017
0
500
1000
1500
2000
2500
1997 (EHR Starts in Use)
2000 ('04 THP Starts)
2005 ('06 New Coord.)
2009 ('07 New Protocols)
2012 ('10 New Pgm Asst.)
2013 (11/'12 New Med Dir)
2014 (New Pt Advocate)
2015 (Decentralization)
Nu
mb
er (
N)
of
Pati
ents
Fenway Health: Trans Health Program Growth, 1997-2015
11
N=11 N=41N=116
N=366
N=879
N=1208
N=1456
N=2017
0
500
1000
1500
2000
2500
1997 (EHR Starts in Use)
2000 ('04 THP Starts)
2005 ('06 New Coord.)
2009 ('07 New Protocols)
2012 ('10 New Pgm Asst.)
2013 (11/'12 New Med Dir)
2014 (New Pt Advocate)
2015 (Decentralization)
Nu
mb
er (
N)
of
Pati
ents
Gender Identity ≠ Sexual Orientation
Sexual orientation – how a person identifies their physical and emotional attraction to others
Transgender people can be of any sexual orientation
Cite: Grant et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Gay & Lesbian Task Force & National Transgender Center for Equality; 2011.
N > 6,450
12
Overview
Terminology: Sex, Gender, and Transgender
Global Health Burden in Transgender People
Situated Vulnerabilities
Participatory Population Perspective
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Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD.
Global health burden and needs of transgender populations: a review.
Need to characterize the global health burden facing transgender populations
Effectively prioritize the geography and content of transgender health research
15
Search, Selection Criteria, and Data Synthesis Review and synthesis of data from peer-reviewed scientific literature
PRISMA Guidelines
Inclusion criteria Published Jan 1, 2008 to Dec 20, 2014 inclusive Any study design, quantitative data, disease burden in trans people Pubmed, Embase, OVID, PsychInfo, Web of Science, ProQuest Search terms: - “transgender” (e.g., hijra, waria, travesti, female-to-male)
- health terms (e.g., HIV, disease, illness, mental health)
Title search, abstract review, full-text review, and data abstraction Completed by two reviewers, third reviewer as a tie-breaker Duplicates removed and excluding non-scientific journals
16
Global Health Burden: Studies in Transgender
Health, 2008-2014
17
116 studies
Number of Studies About Transgender Health
Published Per Year (n=116)
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Distribution of Studies About Transgender
Health by Assigned Sex at Birth (n=116)
19
Health Outcome Categories in Transgender
Health (n=981 Data Points), 2008-2014
20
303
219193
10593
68
0
50
100
150
200
250
300
350
Mental Health Sexual andReproductive
Health
Substance Use Violence/Victimization
Stigma/Discrimination
GeneralHealth
Nu
mb
er
of
Dat
a P
oin
ts (
n)
Health Outcome Category
Limitations Excluded qualitative studies, a rich source of inquiry
Limited to peer-reviewed literature Many non-peer reviewed sources provide invaluable data
Partnerships between community members and researchers to collect data will improve research worldwide
Complex set of search terms and keywords to accurately identify current transgender health research “Transgender” added to PubMED as a MeSH term in 2013
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Gaps and Opportunities No data or limited data in majority of the world
Need for shared lexicon and population definitions
Understudied health conditions (e.g., non-communicable diseases)
Lack of competent primary care and gender affirmation expertise
“Situated vulnerabilities” affect the health and wellbeing of
transgender populations globally
Increase the rigor and reach of
transgender public health research,
programming, practice, and policy
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Overview
Terminology: Sex, Gender, and Transgender
Global Health Burden in Transgender People
Situated Vulnerabilities
Participatory Population Perspective
23
Global Burden of HIV in Transgender Women
Cite: Baral, Poteat, et al., The Lancet Infectious Diseases, 2013
Pooled HIV prevalence = 19.1% (95% CI 17.4–20.7) in
“…in which disadvantaged social groups—such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination—systematically experience worse health or greater health risks than more advantaged social groups.”
Cite: Braveman P. Health disparities and health equity: Concepts and measurement. Ann Rev Public Health, 2006;27:167-194.
need jobs, places to stay, doctors. HIV is just one of the many problems
we deal with.”– MTF age 19
0
10
20
30
40
50
60
70
80
90
Any Bullying In Person By Phone Call Via TextMessage
Online Some OtherWay
We
igh
ted
Pe
rce
nt
(%)
Transgender Non-Transgender Female Non-Transgender Male
Past 12 Month Bullying Victimization
Adj. OR
(95% CI)
p-value
3.58 (2.74, 4.68)
<0.0001
2.93 (2.30, 3.72)
<0.0001
1.68 (1.29, 2.19)
<0.01
1.98 (1.55, 2.53)
<0.0001
3.02 (2.43, 3.75)
<0.0001
2.04 (1.62, 2.58)
<0.0001
Models adjusted for age,
race/ethnicity, family SES,
geographic context.
n=2260n=2840n=442
Reisner et al., J Sex Research, 2015 34
HIV
DiscriminationDepression
Substance Use
Incarceration
Situated
Vulnerabilities
Sexual Networks
Homelessness
Sex Work Family, Peer Rejection
Violence
35
“Preventing HIV in us girls is complicated. We
need jobs, places to stay, doctors. HIV is just one of the many problems
we deal with.”– TF age 19
Discrimination in Healthcare: Project VOICE
Cite: Reisner et al. Legal protections in public accommodations settings: A critical public health issue for transgender and gender non-conforming people. Milbank Quarterly 2015; 93(3): 484-515.
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Discrimination Shapes Healthcare Utilization 452 MA transgender adults - 24% discrimination in healthcare, last 12 mo
+Multivariable models adjusted for: discrimination in other settings, age, race/ethnicity, gender identity, natal sex, gender affirmation, visual gender nonconformity, income, education, employment, health insurance, survey mode.
Discrimination definiton: Mistreatment on the basis of transgender or gender nonconforming
identity/presentation (included verbal harassment and physical assault).
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Attributed Reasons for Everyday Discrimination
Experiences - Project VOICE
83.278.6
68
56.8
43.5
30.1 29.9
23.117.7
13.4 11.9 11.4 10.65.8
GenderIdentityand/or
Expression
HowMasculine or
FeminineYou Appear
SexualOrientation
Sex Age OtherAppearance
Weight Educationand/orIncome
Disability Religion Race Ethnicity OtherReason
Nationality
Pe
rce
nt
(%)
Attributed Reasons for Everyday Discrimination Experiences
Transgender and/or gender nonconforming MA residents ages 18 years or older
Mean (SD) = 4.8 (2.4)
[range 0-14]
Cite: Reisner et al. Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. Journal of Counseling Psychology; in press.
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Multivariable Linear Model, PTSD Symptoms Beta (95% CI) p-value
Number Reasons for Discrimination (cont.) 0.05 (0.01, 0.10) 0.015
Childhood Abuse Age < 15 years 0.29 (0.21, 0.37) <0.0001
IPV 0.18 (0.10, 0.26) <0.0001
Depression 0.23 (0.14, 0.32) <0.0001
Polydrug Use (2+) 0.13 (0.03, 0.23) 0.009
Age (continuous) -0.17 (-0.21, -0.12) <0.0001
FTM vs MTF -0.21 (-0.30, -0.11) <0.0001
Nonbinary Gender Identity vs Binary -0.03 (-0.13, 0.06) 0.493
Social Gender Affirmation (Live Full-Time) 0.13 (0.03, 0.23) 0.014
Medical Gender Affirmation (Hormones and/or Surgery) -0.10 (-0.19, -0.01) 0.043
High Visual GNC vs Moderate/Low 0.17 (0.08, 0.27) 0.0003
People of Color vs White Non-Hispanic -0.05 (-0.15, 0.05) 0.312
Income (cont.) -0.03 (-0.07, 0.02) 0.106
Education (cont.) -0.02 (-0.07, 0.01) 0.262
Unstably Housed vs Stably Housed 0.24 (0.15, 0.33) <0.0001
Sexual Minority (LGBQ) vs Heter0sexual 0.04 (-0.08, 0.15) 0.533
Multivariable Linear Model, PTSD Symptoms
N=412 +Adjusted for survey mode (online vs in-person). All continuous variables z-scored.
44.4% probable PTSD 40
HIV
DiscriminationDepression
Substance Use
Incarceration
Situated
Vulnerabilities
Sexual Networks
Homelessness
Sex Work Family, Peer Rejection
Violence
41
“Preventing HIV in us girls is complicated. We
need jobs, places to stay, doctors. HIV is just one of the many problems
we deal with.”– TF age 19
U.S. Transgender Women (n=3,878)
0
5
10
15
20
25
30
35
40
45
50
Black Non-Hispanic
NativeAmerican/
AlaskanNative Non-
Hispanic
Public HealthInsurance
Uninsured Sex Work HIV-Infected SubstanceUse
PhysicalAssault
SexualAssault
Jail/Prison No Jail/Prison
Reisner, Bailey, Sevelius, Women Health, 2014
Single adjusted multivariable regression model included: Age, gender identity, race/ethnicity, health insurance, income, education, hormones, surgery, geographic region, HIV status, sex work, substance use, smoking , physical and sexual assault, suicide attempt, data collection mode.
National Transgender Discrimination Survey (NTDS): history of jail/prison 19.3% (n=748)
All RRs p<0.05
Pe
rce
nt (%
)
42
U.S. Transgender Women (n=3,878)
0
5
10
15
20
25
30
35
40
45
50
Black Non-Hispanic
NativeAmerican/
AlaskanNative Non-
Hispanic
Public HealthInsurance
Uninsured Sex Work HIV-Infected SubstanceUse
PhysicalAssault
SexualAssault
Jail/Prison No Jail/Prison
Reisner, Bailey, Sevelius, Women Health, 2014
National Transgender Discrimination Survey (NTDS): history of jail/prison 19.3% (n=748)
All RRs p<0.05
Pe
rce
nt (%
)
43
Single adjusted multivariable regression model included: Age, gender identity, race/ethnicity, health insurance, income, education, hormones, surgery, geographic region, HIV status, sex work, substance use, smoking , physical and sexual assault, suicide attempt, data collection mode.
U.S. Transgender Women (n=3,878)
0
5
10
15
20
25
30
35
40
45
50
Black Non-Hispanic
NativeAmerican/
AlaskanNative Non-
Hispanic
Public HealthInsurance
Uninsured Sex Work HIV-Infected SubstanceUse
PhysicalAssault
SexualAssault
Jail/Prison No Jail/Prison
Reisner, Bailey, Sevelius, Women Health, 2014
National Transgender Discrimination Survey (NTDS): history of jail/prison 19.3% (n=748)
All RRs p<0.05
Pe
rce
nt (%
)
44
Single adjusted multivariable regression model included: Age, gender identity, race/ethnicity, health insurance, income, education, hormones, surgery, geographic region, HIV status, sex work, substance use, smoking , physical and sexual assault, suicide attempt, data collection mode.
HIV
DiscriminationDepression
Substance Use
Incarceration
Situated
Vulnerabilities
Sexual Networks
Homelessness
Sex Work Family, Peer Rejection
Violence
45
“Preventing HIV in us girls is complicated. We
need jobs, places to stay, doctors. HIV is just one of the many problems
we deal with.”– TF age 19
Sexual Networks and Partners:Transgender Youth (n=145)
TFn=63
TMn=82
p-value
Mean Age(SD)
19.4 (3.2)
20.5 (2.6)
0.02
People of Color 52.4% 15.8% <0.0001
HIV Infection 7.9% 2.4% 0.13
Condomless Anal and/or Vaginal Sex 52.4% 43.9% 0.31
Casual Sex Partner 69.8% 42.7% 0.001
Main/Primary Sex Partner 25.4% 48.8% 0.004
Sex Work 33.3% 1.2% <0.0001
Depression 42.9% 54.9% 0.15
Current Alcohol Use 50.8% 58.5% 0.35
Current Drug Use 39.7% 32.9% 0.40
Unstably/Marginally Housed 25.4% 13.45 0.07
Reisner, Vetters, et al. AIDS Care, 2015
Bold indicates statistical significance. Reported p-values are from Fisher’s exact tests where cell sizes were small.
TF=Trans Feminine, TM=Trans Masculine
46
Sexual Networks and Partners:Transgender Youth (n=145)
TFn=63
TMn=82
p-value
Mean Age(SD)
19.4 (3.2)
20.5 (2.6)
0.02
People of Color 52.4% 15.8% <0.0001
HIV Infection 7.9% 2.4% 0.13
Condomless Anal and/or Vaginal Sex 52.4% 43.9% 0.31
Casual Sex Partner 69.8% 42.7% 0.001
Main/Primary Sex Partner 25.4% 48.8% 0.004
Sex Work 33.3% 1.2% <0.0001
Depression 42.9% 54.9% 0.15
Current Alcohol Use 50.8% 58.5% 0.35
Current Drug Use 39.7% 32.9% 0.40
Unstably/Marginally Housed 25.4% 13.45 0.07
Reisner, Vetters, et al. AIDS Care, 2015
Bold indicates statistical significance. Reported p-values are from Fisher’s exact tests where cell sizes were small.
TF=Trans Feminine, TM=Trans Masculine
Adjusted Models
Outcome:Condomless Sex
TM Youth+Casual Sex Partner3.06 increase in odds (p=0.03)
TF Youth++Main/Primary Sex Partner 6.76 increase in odds (p=0.01)
The Virginia Transgender Health Initiative Study (THIS)
n=350
50
Recalled Developmental Trajectories
ns 1.83* 1.90* ns ns 1.92* 2.85** 7.09**
11.2
15.6
18.320.7
22.1
24.5
30.4
40.4
10.8
12.7
16.417.9
21.8 21.3
25.6
30.9
Becameaware
transgender
Forced orunwanted sex
First suicideattempt
Physicallyattacked
Tobaccoproblem
Drinkingproblem
Soughtgender
transition
Current age
Mea
n A
ge in
Yea
rsMTF FTM
The Virginia Transgender Health Initiative Study (THIS)
n=229 n=121
Longitudinal Models: *p<0.05
**p<0.01 ns = not significant
ns 1.83* 1.90* ns ns 1.92* 2.85**
51
ns 1.83* 1.90* ns ns 1.92* 2.85** 7.09**
11.2
15.6
18.320.7
22.1
24.5
30.4
40.4
10.8
12.7
16.417.9
21.8 21.3
25.6
30.9
Becameaware
transgender
Forced orunwanted sex
First suicideattempt
Physicallyattacked
Tobaccoproblem
Drinkingproblem
Soughtgender
transition
Current age
Mea
n A
ge in
Yea
rsMTF FTM
The Virginia Transgender Health Initiative Study (THIS)
n=229 n=121
Longitudinal Models: *p<0.05
**p<0.01 ns = not significant
ns 1.83* 1.90* ns ns 1.92* 2.85**
Recalled Developmental Trajectories
52
Overview
Terminology: Sex, Gender, and Transgender
Global Health Burden in Transgender People
Situated Vulnerabilities
Participatory Population Perspective
53
Participatory Population Perspective
Cite: Reisner, Keatley J, Baral S, Villayzan J, Mothopeng T, van der Merwe LL, Hosie A, Chung C. Transgender community voices: A participatory population perspective. Lancet 2016; 388(10042): 327-330.
Feminas Gender-Affirmative Transgender Care to Improve the HIV
Treatment Cascade in Lima, Peru
Aim 1: Formative research Focus groups 48 TW and 19 providers
Aim 2: Interventional study 220 TW (200 completers across 12-mo f/u) Hormones and wrap-around HIV services + peer health navigation Outcomes: HIV testing, linkage to care, viral suppression
Aim 3: Dissemination Community and replication
amfAR Peru PI: LlamaUS MPIs: Mayer & Reisner
58
UNICXS
Anti-violence reporting and response network for transgender people in Peru
Adapt components of Fenway’s Violence Recovery Program (VRP)
Increase capacity of Peruvian partners to respond to pervasive violence faced by transgender people
US PI: Reisner Peru PI: Silva-Santisteban
59
60
Based on feedback that transgender individuals might be denied the right to vote using their DNI, the UNICXS team met with members of the legal network who identified 3 key pieces of advice for people who face this scenario.
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The Way Forward
Address broader social contexts of transgender health
Increase capacity to provide primary care
Improve delivery of gender affirmative care
Decrease barriers to access and utilization of services
Integrate health and human rights approaches
Engage transgender people
Build on community resiliencies
Promote strengths-based efforts
62
“Despite substantial gaps in empirical research, there are sufficient actionable data … surrounding health risks and
resiliencies for transgender people that need interventions.”
Global health burden and needs of transgender populations: a review.Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R,