Publications by authors named "Don Operario"

223 Publications

Prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary individuals.

BMJ Glob Health 2021 09;6(9)

Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background: Testing for COVID-19 and linkage to services is fundamental to successful containment and control of transmission. Yet, knowledge on COVID-19 testing among transgender and non-binary communities remains limited.

Methods: Between October 2020 and November 2020, we examined the prevalence and associations of COVID-19 testing in an online sample of transgender and non-binary people (n=536). Multivariable hierarchical logistic regression analyses examined associations between COVID-19 testing and participants' sociodemographic, mental health, substance use, gender affirmation, economic changes and healthcare experiences.

Results: Prevalence of COVID-19 testing in this sample was 35.5% (n=190/536). In the final model, transgender and non-binary participants from upper socioeconomic income background and Europe, who reported having active alcohol use disorder, limited access to gender-affirming surgery, had more than 20% reduction in income, and experienced mistreatment in a health facility due to gender identity had significantly increased odds of COVID-19 testing (all p<0.05); those who reported recent tobacco use had significantly lower odds of COVID-19 testing (p=0.007).

Conclusions: These findings highlight structural disparities in COVID-19 testing and reinforce the importance of increasing testing strategies for transgender and non-binary populations.
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http://dx.doi.org/10.1136/bmjgh-2021-006808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438577PMC
September 2021

Preferences for Conditional Economic Incentives to Improve Pre-exposure Prophylaxis Adherence: A Discrete Choice Experiment Among Male Sex Workers in Mexico.

AIDS Behav 2021 Aug 27. Epub 2021 Aug 27.

Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.
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http://dx.doi.org/10.1007/s10461-021-03443-1DOI Listing
August 2021

Sexual Prejudice and Comfort to Provide Services to Men Who Have Sex with Men Among HIV Healthcare Workers in Western Kenya: Role of Interpersonal Contact.

AIDS Behav 2021 Aug 18. Epub 2021 Aug 18.

Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI, USA.

Sexual minority men living in Africa, where many countries criminalize same-sex behavior, are vulnerable to HIV and experience significant barriers to HIV care. Sexual prejudice in healthcare settings is a key contributor to these barriers. Building on social psychological models of prejudice and interpersonal contact at the clinic, we examined the associations between healthcare workers' sexual prejudice and their comfort to provide care to MSM, and assessed the moderating role of workers' prior interpersonal contact with MSM. A cross-sectional survey of 147 healthcare workers varying in level of training and expertise working in HIV care organizations was conducted in western Kenya. Sexual prejudice was negatively associated with comfort to provide care to MSM. Prior interpersonal contact with MSM moderated the association between sexual prejudice and comfort to provide care to MSM among nurses/counselors, such that those with low prior contact and high sexual prejudice were the most uncomfortable providing care to MSM. Interventions are needed to address sexual prejudice and encourage positive forms of interpersonal contact with MSM, especially with nurses and counselors who might have more and varied patient interactions, to improve access to the continuum of HIV prevention and care for MSM in Kenya.
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http://dx.doi.org/10.1007/s10461-021-03440-4DOI Listing
August 2021

Mindfulness-based interventions for medication adherence: A systematic review and narrative synthesis.

J Psychosom Res 2021 Oct 26;149:110585. Epub 2021 Jul 26.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States. Electronic address:

Objective: Inadequate medication adherence is a significant limitation for achieving optimal health outcomes across chronic health conditions. Mindfulness-based interventions (MBIs) have been increasingly applied to promote medical regimen adherence as MBIs have been shown to improve patient-level barriers to adherence (i.e., depressive symptoms, cognitive impairment, stress). The purpose of this review is to investigate the state of research regarding MBIs targeting medication adherence in chronic illnesses and to identify evidence gaps to inform future studies.

Methods: The search reviewed 5 databases (e.g., PubMed, PsycINFO, Embase, CINAHL, Proquest Thesis/Dissertations) to identify trials that quantitatively evaluated the effect of MBIs on medication adherence. Study abstracts and full texts were screened identifying eligible studies, and findings were summarized using a narrative synthesis.

Results: A total of 497 studies were reviewed; 41 were eligible for full text review and 9 were included in narrative synthesis: seven were RCTs and two were pre-post designs. Study quality varied, with five rated moderate or high risk for bias. Clinical populations tested included living with HIV (k = 3), cardiovascular disease (k = 3), psychological disorders (k = 2), and men who underwent a radical prostatectomy (k = 1). Four studies found significant improvements in medication adherence, however only two of these studies had low risk of bias.

Conclusions: Research on MBI's for medication adherence is developing, but the effectiveness of MBIs remains unclear due to the nascent stage of evidence and methodological limitations of existing studies. Researchers should prioritize rigorous experimental designs, theory-driven investigations of behavioral mechanisms, and the use of objective measurements of adherence.
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http://dx.doi.org/10.1016/j.jpsychores.2021.110585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453130PMC
October 2021

Pre-exposure prophylaxis for transgender women and men who have sex with men: qualitative insights from healthcare providers, community organization-based leadership and end users in coastal Kenya.

Int Health 2021 Jul 29. Epub 2021 Jul 29.

KEMRI-Wellcome Trust Research Program, Kilifi, Kenya.

Transgender women (TW) and men who have sex with men (MSM) in Kenya are disproportionately affected by human immunodeficiency virus (HIV) and would benefit substantially from pre-exposure prophylaxis (PrEP). We conducted focus group discussions (FGDs) with healthcare providers (HCPs) and TW/MSM leadership and in-depth interviews (IDIs) with PrEP-experienced MSM and TW to learn about perceived and actual barriers to PrEP programming. Eleven HCP and 10 TW/MSM leaders participated in FGDs before PrEP roll-out (January 2018) and 12 months later. Nineteen PrEP end-users (11 MSM and 8 TW) participated in IDIs. Topic guides explored PrEP knowledge, HIV acquisition risk, gender identity, motivation for PrEP uptake and adherence and PrEP-dispensing venue preferences. Braun and Clarke thematic analysis was applied. Four themes emerged: limited preparedness of HCPs to provide PrEP to TW and MSM, varied motivation for PrEP uptake and persistence among end users, lack of recognition of TW by HCPs and suggestions for PrEP programming improvement from all stakeholders. Providers' reluctance to prescribe PrEP to TW and distrust of TW towards providers calls for interventions to improve the capacity of service environments and staff HIV preventive care. Alternative locations for PrEP provision, including community-based sites, may be developed with TW/MSM leaders.
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http://dx.doi.org/10.1093/inthealth/ihab043DOI Listing
July 2021

A mindfulness-based mobile health (mHealth) intervention among psychologically distressed university students in quarantine during the COVID-19 pandemic: A randomized controlled trial.

J Couns Psychol 2021 Jul 15. Epub 2021 Jul 15.

Department of Behavioral and Social Sciences, Brown University School of Public Health.

This randomized controlled trial evaluated the effect of a mindfulness-based mobile health (mHealth) intervention, tailored to the pandemic context, among young adult students (N = 114) with elevated anxiety and/or depressive symptoms during quarantine in China, compared to a time- and attention-matched social support-based mHealth control. At baseline, postintervention (1 month), and 2-month follow-up, participants completed self-reports of primary outcomes (anxiety and depression), secondary outcomes (mindfulness and social support), and emotional suppression as a culturally relevant mechanism of change. Feasibility and acceptability were also evaluated. Using intent-to-treat (ITT) analysis, linear mixed effects models showed that compared to social support mHealth, mindfulness mHealth had a superior effect on anxiety (p = .024, between-group d = 0.72). Both conditions improved on depression (baseline-to-FU ds > 1.10, between-group difference not significant, d = 0.36 favoring mindfulness). There was an interaction of Emotional suppression reduction × Condition in the improvement of anxiety and depression. Further, mindfulness mHealth was demonstrated to be more feasible and acceptable in program engagement, evaluation, skills improvement, and perceived benefit. Retention was high in both conditions (>80%). The difference in self-reported adverse effect was nonsignificant (3.9% in mindfulness and 8.7% in social support). Results of this pilot trial suggest that both mindfulness and social support, delivered via mHealth, show promise in reducing distress among young adults in quarantine, with mindfulness being particularly effective in addressing anxiety. Successful implementation and dissemination of this mHealth intervention approach have the potential for addressing the psychological consequences of the pandemic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000568DOI Listing
July 2021

A mindfulness-based mobile health (mHealth) intervention among psychologically distressed university students in quarantine during the COVID-19 pandemic: A randomized controlled trial.

J Couns Psychol 2021 Jul 15. Epub 2021 Jul 15.

Department of Behavioral and Social Sciences, Brown University School of Public Health.

This randomized controlled trial evaluated the effect of a mindfulness-based mobile health (mHealth) intervention, tailored to the pandemic context, among young adult students (N = 114) with elevated anxiety and/or depressive symptoms during quarantine in China, compared to a time- and attention-matched social support-based mHealth control. At baseline, postintervention (1 month), and 2-month follow-up, participants completed self-reports of primary outcomes (anxiety and depression), secondary outcomes (mindfulness and social support), and emotional suppression as a culturally relevant mechanism of change. Feasibility and acceptability were also evaluated. Using intent-to-treat (ITT) analysis, linear mixed effects models showed that compared to social support mHealth, mindfulness mHealth had a superior effect on anxiety (p = .024, between-group d = 0.72). Both conditions improved on depression (baseline-to-FU ds > 1.10, between-group difference not significant, d = 0.36 favoring mindfulness). There was an interaction of Emotional suppression reduction × Condition in the improvement of anxiety and depression. Further, mindfulness mHealth was demonstrated to be more feasible and acceptable in program engagement, evaluation, skills improvement, and perceived benefit. Retention was high in both conditions (>80%). The difference in self-reported adverse effect was nonsignificant (3.9% in mindfulness and 8.7% in social support). Results of this pilot trial suggest that both mindfulness and social support, delivered via mHealth, show promise in reducing distress among young adults in quarantine, with mindfulness being particularly effective in addressing anxiety. Successful implementation and dissemination of this mHealth intervention approach have the potential for addressing the psychological consequences of the pandemic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000568DOI Listing
July 2021

From imperialism to inpatient care: Work differences of Filipino and White registered nurses in the United States and implications for COVID-19 through an intersectional lens.

Gend Work Organ 2021 Apr 16. Epub 2021 Apr 16.

Department of Ethnic Studies University of California, Berkeley Berkeley CA USA.

In the United States, nursing is the largest healthcare profession, with over 3.2 million registered nurses (RNs) nationwide and comprised of mostly women. Foreign-trained RNs make up 15 percent of the RN workforce. For over half a century, the U.S. healthcare industry has recruited these RNs in response to nurse shortages in hospitals and nursing homes. Philippines-trained RNs make up 1 out of 20 RNs in this country and continue to be the largest group of foreign-trained nurses today. Recently, the news media has publicized the many deaths of Filipino RNs as a result of the COVID-19 pandemic in the United States. Given the imperial historical ties between these two countries in the context of the nursing profession and the enduring labor inequities that persist, this nationally representative study is one of the few to our knowledge to not only quantitatively examine the current work differences in characteristics and experiences of Philippines-trained RNs and U.S.-trained white RNs practicing in the United States today, but to also do so from an intersectionality lens. The overall aim of this paper is to illuminate how these differences may serve as potential factors contributing to the disproportionate number of Filipino nurses' COVID-19 related vulnerability and deaths in the workplace.
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http://dx.doi.org/10.1111/gwao.12657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251240PMC
April 2021

From imperialism to inpatient care: Work differences of Filipino and White registered nurses in the United States and implications for COVID-19 through an intersectional lens.

Gend Work Organ 2021 Apr 16. Epub 2021 Apr 16.

Department of Ethnic Studies University of California, Berkeley Berkeley CA USA.

In the United States, nursing is the largest healthcare profession, with over 3.2 million registered nurses (RNs) nationwide and comprised of mostly women. Foreign-trained RNs make up 15 percent of the RN workforce. For over half a century, the U.S. healthcare industry has recruited these RNs in response to nurse shortages in hospitals and nursing homes. Philippines-trained RNs make up 1 out of 20 RNs in this country and continue to be the largest group of foreign-trained nurses today. Recently, the news media has publicized the many deaths of Filipino RNs as a result of the COVID-19 pandemic in the United States. Given the imperial historical ties between these two countries in the context of the nursing profession and the enduring labor inequities that persist, this nationally representative study is one of the few to our knowledge to not only quantitatively examine the current work differences in characteristics and experiences of Philippines-trained RNs and U.S.-trained white RNs practicing in the United States today, but to also do so from an intersectionality lens. The overall aim of this paper is to illuminate how these differences may serve as potential factors contributing to the disproportionate number of Filipino nurses' COVID-19 related vulnerability and deaths in the workplace.
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http://dx.doi.org/10.1111/gwao.12657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251240PMC
April 2021

Correction to: Psychiatric symptoms, risk, and protective factors among university students in quarantine during the COVID-19 pandemic in China.

Global Health 2021 Apr 26;17(1):52. Epub 2021 Apr 26.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.

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http://dx.doi.org/10.1186/s12992-021-00701-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072730PMC
April 2021

Does Discrimination Affect Whether Transgender People Avoid or Delay Healthcare?: A Nationwide Cross-sectional Survey in South Korea.

J Immigr Minor Health 2021 Apr 21. Epub 2021 Apr 21.

Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea.

This study examined the association between perceived discrimination and healthcare avoidance and delay (HAD) among transgender adults in South Korea (hereafter Korea). We conducted a nationwide cross-sectional survey of 244 Korean transgender adults in 2017. Discrimination within the last 12 months was categorized into four groups based on the reason(s) of discrimination experienced: (1) 'never experienced' discrimination, (2) 'only due to transgender identity,' (3) 'due to reason(s) other than transgender identity,' and (4) 'due to both transgender identity and other reason(s).' Korean transgender adults who experienced discrimination 'only due to transgender identity' and 'due to both transgender identity and other reason(s)' reported 1.91-times (95% CI 1.02-3.55) and 1.96-times (95% CI 1.32-2.92) higher prevalence of past 12-month HAD, respectively, than those who had no such experiences. Our findings suggest that institutional efforts are needed to protect transgender people from discrimination, which can contribute to improved access to healthcare among transgender populations in Korea.
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http://dx.doi.org/10.1007/s10903-021-01193-9DOI Listing
April 2021

Interest in COVID-19 vaccine trials participation among young adults in China: Willingness, reasons for hesitancy, and demographic and psychosocial determinants.

Prev Med Rep 2021 Jun 12;22:101350. Epub 2021 Mar 12.

Brown University School of Public Health, Department of Behavioral and Social Sciences, United States.

With the demand for rapid COVID-19 vaccine development and evaluation, this paper aimed to describe the prevalence and correlates of willingness to participate in COVID-19 vaccine trials among university students in China. A cross-sectional survey with 1912 Chinese university students was conducted during March and April 2020. Bivariate and multivariate analyses were performed to identify variables associated with willingness to participate. The majority of participants (64.01%) indicated willingness to participate in COVID-19 vaccine trials. Hesitancy over signing informed consent documents, concerns over time necessary for participating in a medical study, and perceived COVID-19 societal stigma were identified as deterrents, whereas lower socioeconomic status, female gender, perception of likely COVID-19 infection during the pandemic, and COVID-19 prosocial behaviors were facilitative factors. Further, public health mistrust and hesitancy over signing informed consent documents had a significant interactive effect on vaccine trial willingness. High standards of ethical and scientific practice are needed in COVID-19 vaccine research, including providing potential participants full and accurate information and ensuring participation free of coercion, socioeconomic inequality, and stigma. Attending to the needs of marginalized groups and addressing psychosocial factors including stigma and public health mistrust may also be important to COVID-19 vaccine development and future uptake.
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http://dx.doi.org/10.1016/j.pmedr.2021.101350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009141PMC
June 2021

Socioeconomic Status and Psychosocial Resources Mediate Racial/Ethnic Differences in Psychological Health Among Gay and Bisexual Men: A Longitudinal Analysis Using Structural Equation Modeling.

Am J Mens Health 2021 Mar-Apr;15(2):15579883211001197

School of Public Health, Brown University, Providence, RI, USA.

A large body of research demonstrates disparities in psychological health attributed to sexual minority identity, racial/ethnic minority identity, and socioeconomic status (SES). Fewer studies have explicated the role of these multiple attributes on psychological health and explored the role of SES and psychosocial resources in determining outcomes. We analyzed data from Project STRIDE, a longitudinal survey involving a diverse sample of gay and bisexual adult men ( = 198). Using structural equation modeling, we tested hypothesized direct and indirect effects of race/ethnicity, SES, and three psychosocial mediational variables (collective self-efficacy, everyday discrimination, internalized homophobia) on two outcome variables-psychological and social well-being-assessed at 1-year follow-up. Our model indicated that: (1) race/ethnicity and SES were significantly associated with each other and with each psychosocial mediator; (2) higher SES was directly and indirectly associated with both measures of well-being; and (3) collective self-esteem and everyday discrimination mediated the association between SES and both measures of well-being. The model also indicated that racial/ethnic associations with psychological mediators and outcomes are evident in the context of SES, but these effects might be suppressed when the model does not consider SES. Findings highlight the critical role of SES and race/ethnicity in determining the psychological and social well-being of sexual minority men. Specification of mediating variables-collective self-efficacy, everyday discrimination, internalized homophobia-indicates potential intervention targets to improve psychological and social health in sexual minority men. Associations between race/ethnicity and SES support the need for intersectional frameworks in addressing the health of sexual minority men.
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http://dx.doi.org/10.1177/15579883211001197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970305PMC
March 2021

Psychological Stress, Smoking, and Hazardous Drinking Behaviors among South Korean Adults: Findings from the Korean National Health and Nutrition Examination Survey.

J Subst Use 2021 13;26(1):13-20. Epub 2020 May 13.

Brown University School of Public Health, Department of Behavioral and Social Sciences, Providence, RI, USA.

Introduction: There is growing attention to mental health as a contributor to behavioral health in South Korea. We investigated the prevalence of psychological stress and its associations with cigarette smoking and drinking behaviors among a nationally representative sample of South Korean adults.

Methods: Using data from 14,855 adults aged ≥19 years who participated in the 2013 to 2016 Korea National Health and Nutrition Examination Survey (KNHANES), we performed weighted logistic regression to examine the associations between stress and three binary outcome variables: cigarette smoking, heavy episodic drinking and frequent drinking.

Results: 27.2% of participants reported high stress. Controlling for sociodemographic covariates, high stress was associated with 1.54 times the odds (p<0.001) of being a smoker, 1.25 times the odds (p<0.001) of being a heavy episodic drinker, and 1.23 times the odds (p<0.001) of being a frequent drinker. There was evidence of effect modification by gender and occupation, such that the effects of stress on these behaviors were particularly stronger among women and pink-collar (service industry) workers (compared to men and white-collar workers).

Conclusions: Future policies that aim to address smoking and drinking behaviors in South Korea should consider stress reduction and coping strategies, especially among women and pink-collar workers.
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http://dx.doi.org/10.1080/14659891.2020.1760379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954234PMC
May 2020

Transgender-specific developmental milestones and associated experiences of violence, discrimination, and stigma among Filipinx transgender women who are sexually active with men.

PLoS One 2021 9;16(3):e0248248. Epub 2021 Mar 9.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America.

Background: For transgender people, reaching transgender (trans)-specific developmental milestones, including recognizing and expressing one's identity, plays an integral role in overall health, wellbeing, and the pursuit of gender affirmation. Yet trans people continue to face minority stressors, including structural violence (i.e., discrimination, violence, and stigma), which may interfere with the achievement of these milestones. Among trans women specifically, however, potential associations between gender developmental milestones and structural violence are not well characterized in the literature. In a sample of Filipinx (i.e., an inclusive term for describing non-binary genders in the Philippines) trans women who are sexually active with men (trans-WSM), we thus sought to: (a) describe the mean ages at which gender developmental milestones occur and (b) examine the associations between structural violence and mean ages at which at which Filipinx trans-WSM experience trans-specific developmental milestones.

Methods: Using data from Project #ParaSaAtin, an online survey of Filipinx trans-WSM (n = 139), we mapped age-estimates per trans-specific milestones and then tested whether structural violence is associated with the mean age at which trans women experience trans-specific developmental milestones.

Results: Overall, participants who reported higher levels of discrimination, stigma, and violence also experienced a later age for nearly each milestone (i.e., initial self-awareness of transfeminine identity, transfeminine expression in private, transfeminine expression in public, first consensual oral/vaginal/anal sex with a cisgender male partner, first consensual oral/vaginal/anal sex with a cisgender male partner as a trans women, and hormone integration) (all p-values <0.05). Of note, the single exception to this pattern was the non-significant association between stigma and initial disclosure of transfeminine identification to another person.

Conclusion: Results are consistent with psychological literature outlining a temporal sequence of developmental milestones among young trans-WSM. For young trans-WSM in the Philippines, data from this study demonstrate significant associations between structural violence and the achievement of developmental milestones. These findings highlight the need for trauma-informed, strengths-based programming and institutional policies that measure and mitigate anti-trans violence.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248248PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942990PMC
March 2021

Expanding Gender-Based Health Equity Framework for Transgender Populations.

Transgend Health 2021 Feb 15;6(1):1-4. Epub 2021 Feb 15.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.

The gender-transformative approach to health promotion in the United States and globally has been central to defining gender as a determinant of health and advancing health programs, services, and policies that respond to gender-based inequities. However, current gender frameworks are built on historical perspectives that center cisgender people's experiences and reinforce the gender binary. This restricted focus does not respond to health inequities experienced by transgender people-to the detriment of health programs, services, and policies. As transgender people's health and rights continue to garner attention in movements across health services and policy spaces, it is crucial for frameworks to be expansively redefined to achieve truly transformative gender equality and equity for all gender identities and expressions.
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http://dx.doi.org/10.1089/trgh.2020.0026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906221PMC
February 2021

Asian, Latinx, or Multiracial? Assessing Filipinxs' Health Conditions and Outcomes by Aggregate Ethnic Category.

J Racial Ethn Health Disparities 2021 Feb 16. Epub 2021 Feb 16.

UCLA Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, CA, USA.

Introduction: Filipinxs are the second-largest Asian subgroup in the USA. While Filipinxs are most often considered Asian when constructing aggregate ethnic categories, recent research has identified a trend of a small portion of Filipinxs identifying as Latinx or multiracial. However, little research had addressed how identification with different aggregate ethnic categories may have implications for identifying health disparities among Filipinxs and how these compare to non-Hispanic whites.

Methods: Bivariate and multivariable regression analyses using 2011-2018 California Health Interview Survey data, comparing Asian Filipinxs, Latinx Filipinxs, and multiracial Filipinxs.

Results: In bivariate analyses, Asian Filipinxs had a higher prevalence of diabetes than Latinx or multiracial Filipinxs. After controlling for sociodemographics, Latinx Filipinxs had significantly lower odds of having diabetes or heart disease than Asian Filipinxs. Compared to non-Latinx Whites, Asian Filipinxs reported higher odds of being in fair/poor health, obese or overweight, high blood pressure, and diabetes, multiracial Filipinxs reported higher odds of being obese or overweight, and Latinx Filipinxs reported lower odds of heart disease.

Discussion: These findings suggest emerging differences in health linked to identification with different ethnic categories, underscoring the need to investigate nuances among Filipinxs in future research as well as highlighting the utility of emerging sociological insights in health research.
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http://dx.doi.org/10.1007/s40615-021-00971-3DOI Listing
February 2021

Psychiatric symptoms, risk, and protective factors among university students in quarantine during the COVID-19 pandemic in China.

Global Health 2021 01 25;17(1):15. Epub 2021 Jan 25.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.

Background: The COVID-19 pandemic has made unprecedented impact on the psychological health of university students, a population vulnerable to distress and mental health disorders. This study investigated psychiatric symptoms (anxiety, depression, and traumatic stress) during state-enforced quarantine among university students in China (N = 1912) through a cross-sectional survey during March and April 2020.

Results: Psychiatric symptoms were alarmingly prevalent: 67.05% reported traumatic stress, 46.55% had depressive symptoms, and 34.73% reported anxiety symptoms. Further, 19.56% endorsed suicidal ideation. We explored risk and protective factors of psychological health, including demographic variables, two known protective factors for mental health (mindfulness, perceived social support), four COVID-specific factors (COVID-19 related efficacy, perceived COVID-19 threat, perceived COVID-19 societal stigma, COVID-19 prosocial behavior) and screen media usage. Across symptom domains, mindfulness was associated with lower symptom severity, while COVID-19 related financial stress, perceived COVID-19 societal stigma, and perceived COVID-19 threat were associated with higher symptom severity. COVID-19 threat and COVID-19 stigma showed main and interactive effects in predicting all mental health outcomes, with their combination associated with highest symptom severity. Screen media device usage was positively associated with depression. Female gender and COVID-19 prosocial behavior were associated with higher anxiety, while COVID-19 self-efficacy associated with lower anxiety symptoms.

Conclusions: Findings suggest high need for psychological health promotion among university students during the COVID-19 pandemic and inform an ecological perspective on the detrimental role of stigma during an emerging infectious disease outbreak. Interventions targeting multi-level factors, such as promoting mindfulness and social support at individual and interpersonal levels while reducing public stigma about COVID-19, may be particularly promising. Attending to the needs of disadvantaged groups including those financially impacted by COVID-19 is needed.
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http://dx.doi.org/10.1186/s12992-021-00663-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829620PMC
January 2021

"I wish to remain HIV negative": Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya.

PLoS One 2021 19;16(1):e0244226. Epub 2021 Jan 19.

KEMRI-Wellcome Trust Research Program, Kilifi, Kenya.

Background: Transgender women (TGW) and men who have sex with men (MSM) in sub-Saharan Africa have high HIV acquisition risks and can benefit from daily pre-exposure prophylaxis (PrEP). We assessed PrEP adherence by measuring tenofovir-diphosphate (TFV-DP) levels and explore motives for PrEP persistence in TGW and MSM.

Methods: Participants were enrolled in a one-year PrEP programme and made quarterly visits irrespective of whether they were still using PrEP. At their month 6 visit, participants provided a dried blood spot to test for TFV-DP levels; protective levels were defined as those compatible with ≥4 pills per week (700-1249 fmol/punch). Before TFV-DP levels were available, a sub-set of these participants were invited for an in-depth interview (IDI). Semi-structured IDI topic guides were used to explore motives to uptake, adhere to, and discontinue PrEP. IDI data were analyzed thematically.

Results: Fifty-three participants (42 MSM and 11 TGW) were enrolled. At month 6, 11 (20.7%) participants (8 MSM and 3 TGW) were lost to follow up or stopped taking PrEP. Any TFV-DP was detected in 62.5% (5/8) of TGW vs. 14.7% of MSM (5/34, p = 0.01). Protective levels were detected in 37.5% of TGW (3/8), but not in any MSM. Nineteen IDI were conducted with 7 TGW and 9 MSM on PrEP, and 1 TGW and 2 MSM off PrEP. Unplanned or frequent risky sexual risk behaviour were the main motives for PrEP uptake. Among participants on PrEP, TGW had a more complete understanding of the benefits of PrEP. Inconsistent PrEP use was attributed to situational factors. Motives to discontinue PrEP included negative reactions from partners and stigmatizing healthcare services.

Conclusion: While MSM evinced greater adherence challenges in this PrEP programme, almost 40% of TGW were protected by PrEP. Given high HIV incidences in TGW these findings hold promise for TGW PrEP programming in the region.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244226PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815127PMC
April 2021

Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City.

Infect Dis Poverty 2021 Jan 19;10(1). Epub 2021 Jan 19.

Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 South Main Street, Box G-121S-2, Providence, RI, 02912, USA.

Background: Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City.

Methods: From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model.

Results: Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15-10.31], chlamydia (5.15; 95% CI: 2.58-9.34), gonorrhea (3.93; 95% CI: 1.88-7.83), syphilis (13.04; 95% CI: 8.24-19.94), hepatitis B (2.11; 95% CI: 0.53-4.89), hepatitis C (0.95; 95% CI: 0.00-3.16), any STI except HIV (30.99; 95% CI: 21.73-40.26), and any STI including HIV (50.08; 95% CI: 37.60-62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00-0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse.

Conclusions: Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.
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http://dx.doi.org/10.1186/s40249-020-00792-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814587PMC
January 2021

The Association Between Moderate and Serious Mental Health Distress and General Health Services Utilization Among Chinese, Filipino, Japanese, Korean, and Vietnamese Adults in California.

J Racial Ethn Health Disparities 2021 Jan 15. Epub 2021 Jan 15.

Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA.

Introduction: A growing body of literature has indicated that disaggregated analyses using distinct Asian subgroups allow for identification of varying mental health challenges and health services utilization. In this study, we examined the associations between distress and health services utilization among five Asian subgroups: Chinese, Korean, Japanese, Filipino, and Vietnamese adults in California.

Materials And Methods: Using a combined dataset using the 2011-2018 cross-sectional cycles of the California Health Interview survey, we assessed moderate and serious distress and four health services utilization indicators in a set of disaggregated analyses among adults 18 years of age and older in five Asian subgroups. We performed bivariate and multivariable analyses.

Results: The prevalence of and associations between moderate and serious distress and gaps in health services utilization varied among each Asian subgroup. Koreans had the highest prevalence of moderate and serious distress and the most gaps in health services utilization. Compared to those without moderate distress (p < .05), Japanese adults were more likely to delay care. Compared to those without serious distress (p < .05), Chinese adults who experienced serious distress were more likely to delay both medications and care, whereas Filipino and Vietnamese adults were more likely to delay medications.

Discussion: Disaggregating health data elucidates the impact of mental distress on healthcare-seeking behaviors among specific Asian subgroups. Identifying these influences can facilitate future tailored interventions, yet fully understanding the mechanism linking mental distress and healthcare usage will necessitate a comprehensive assessment of structural influences and Asian American experiences without otherization.
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http://dx.doi.org/10.1007/s40615-020-00946-wDOI Listing
January 2021

Cultural adaptation and validation of a measure of prejudice against men who have sex with men among healthcare providers in western Kenya.

Glob Public Health 2020 Dec 11:1-15. Epub 2020 Dec 11.

Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI, USA.

Sexual prejudice toward men who have sex with men (MSM) is a pressing concern in sub-Saharan Africa (SSA). Given the high HIV infection risk among this population, sexual prejudice perpetuated by healthcare providers, affects access to and willingness of MSM to seek HIV care services. However, data on healthcare providers' attitudes towards MSM in SSA are limited, and there are no locally-adapted measures of sexual prejudice. We adapted a scale to measure sexual prejudice with a sample of 147 healthcare providers in western Kenya. Results from exploratory factor analysis revealed a single-factor structure. The scale demonstrated high internal consistency with Cronbach's  = 0.91. Healthcare providers who had prior interpersonal contact with MSM, had ever been trained on counselling MSM, and had higher knowledge about MSM health needs reported lower sexual prejudice scores, compared with peers who lacked these experiences ( < 0.001). In contrast, healthcare providers who had experienced secondary stigma (negative judgments from peers and community) for providing care to MSM reported higher scores of sexual prejudice scale ( < 0.001) compared with providers who had not experienced secondary stigma. The scale provides a contextualised tool to assess healthcare providers' attitudes toward MSM in Kenya and countries in SSA with similar cultural norms.
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http://dx.doi.org/10.1080/17441692.2020.1860248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192581PMC
December 2020

Intimate Partner Violence and Sexual Agency in a Nationally Representative Sample of Women and Girls in the Philippines.

J Interpers Violence 2020 Dec 10:886260520976208. Epub 2020 Dec 10.

Brown University, Providence, RI, USA.

This study examined the prevalence of intimate partner violence (Intimate Partner Violence) and its associations with sexual agency among women and adolescent girls in the Philippines. Data came from the 2017 Philippines National Demographic and Health Survey (DHS), a nationally representative, cross-sectional survey of women and girls ages 15-49. Participants included 11,727 women and girls who reported having a current male partner. Survey measures included three indicators of Intimate Partner Violence (physical, sexual, emotional), ability to refuse sex, ability to insist on condom use, perception that a husband/boyfriend can be justified in hitting or beating his wife/girlfriend, and sociodemographic characteristics. Descriptive and multivariable statistical analyses were conducted, with survey weightings used to account for the complex survey design. Overall, 23.9% reported Intimate Partner Violence in their current partnership (10.1% physical violence, 3.4% sexual violence, 19.0% emotional violence), 11.2% believed a husband or partner could be justified in hitting or beating their wife, 10.5% reported being unable to refuse sex with their partner, and 20.4% were unable to ask their partner to use a condom. In multivariable analyses, experiences of sexual (OR .68; 95% CI .50, .92), physical (OR .83; 95% CI .68, 1.02), and emotional violence (OR .69; 95% CI .58, .81) were associated with lower adjusted odds of being able to ask a partner to use a condom. When placed in the same model, emotional violence had the strongest association with lower odds of negotiating condom use with partner (OR .70; 95% CI .57, .85). Perception that a husband/boyfriend can be justified in hitting or beating his wife/girlfriend was associated with lower ability to refuse sex and ask a partner to use a condom. Findings indicate a need for further investment in interventions to prevent Intimate Partner Violence and support the sexual health and agency of women and girls who have experienced Intimate Partner Violence in the Philippines.
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http://dx.doi.org/10.1177/0886260520976208DOI Listing
December 2020

Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the 'It Takes Two' intervention.

BMJ Open 2020 10 15;10(10):e038723. Epub 2020 Oct 15.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA

Introduction: HIV transmission and acquisition risk among transgender women is particularly high in the context of primary partnerships. This project extends a previous pilot couples-focused HIV intervention programme, which was shown to be feasible, acceptable and promising in reducing sexual risk behaviour among transgender women and their partners. This randomised controlled trial (RCT) tests the efficacy of this culturally sensitive HIV prevention programme for HIV-serodiscordant and HIV-negative seroconcordant transgender women and their partners.

Methods And Analysis: To finalise the protocol for trial, we used qualitative methods to hone eligibility criteria, refine the intervention and control manuals, and name and brand the intervention ('It Takes Two'). The RCT investigates the effects of the It Takes Two intervention on Composite Risk for HIV (CR-HIV) among 100 couples. CR-HIV is a binary indicator of couple HIV risk using validated measures of sexual behaviour, pre-exposure prophylaxis use among HIV-negative participants and viral suppression among participants living with HIV. Using a two-arm RCT, we will examine intervention effects on CR-HIV at 12-month follow-up comparing transgender women and their partners randomised to the intervention versus control (HIV prevention information only).

Ethics And Dissemination: This study has been reviewed and approved by the University of California, San Francisco (19-28624) and the University of Michigan (HUM00147690) Institutional Review Boards. Participants provide informed consent before taking part of the study activities. Results will be published in peer-reviewed journals and presented at scientific conferences. We will make our results available to the community of researchers and general public interested in transgender health to avoid unintentional duplication of research, as well as to others in the health and social services community, including LGBT community-based organisations, AIDS service organisations and other transgender-serving organisations. The full de-identified dataset and codebook will be shared at the University of Michigan Digital Repository.

Trial Registration Number: NCT04067661.
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http://dx.doi.org/10.1136/bmjopen-2020-038723DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566735PMC
October 2020

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States.

AIDS 2021 02;35(2):177-191

Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island.

Objective: To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

Methods: We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

Results: A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

Conclusion: HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.
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http://dx.doi.org/10.1097/QAD.0000000000002713DOI Listing
February 2021

Cultural context matters: Testing the minority stress model among Chinese sexual minority men.

J Couns Psychol 2020 Oct 8. Epub 2020 Oct 8.

Department of Psychiatry and Human Behavior.

Minority stress theory (e.g., Meyer, 2003b), a model for understanding mental health disparities affecting sexual minorities, has primarily been tested in Western samples yet has not been carefully applied to the experiences of sexual minorities in a global context, including in East Asian countries. Combining minority stress theory with considerations of Chinese culture, the current study tested the associations among norm conformity, distal minority stressor (enacted stigma), proximal minority stressors (sexual identity concerns and concealment), lesbian, gay, and bisexual (LGB) family support, and psychological distress among Chinese sexual minority men ( = 748). Structural equation modeling showed that sexual identity concerns mediated the associations of norm conformity, enacted stigma, and lower family support with concealment. Psychological distress was associated with enacted stigma and lower family support, but not with proximal stressors (sexual identity concerns and concealment). Alternative model testing found sexual identity acceptance concerns predicted psychological distress and mediated the associations of norm conformity and LGB family support with distress. Findings provide partial support for the minority stress model in a Chinese context and suggest the importance of incorporating cultural considerations into minority stress conceptualizations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026770PMC
October 2020

Cultural context matters: Testing the minority stress model among Chinese sexual minority men.

J Couns Psychol 2020 Oct 8. Epub 2020 Oct 8.

Department of Psychiatry and Human Behavior.

Minority stress theory (e.g., Meyer, 2003b), a model for understanding mental health disparities affecting sexual minorities, has primarily been tested in Western samples yet has not been carefully applied to the experiences of sexual minorities in a global context, including in East Asian countries. Combining minority stress theory with considerations of Chinese culture, the current study tested the associations among norm conformity, distal minority stressor (enacted stigma), proximal minority stressors (sexual identity concerns and concealment), lesbian, gay, and bisexual (LGB) family support, and psychological distress among Chinese sexual minority men ( = 748). Structural equation modeling showed that sexual identity concerns mediated the associations of norm conformity, enacted stigma, and lower family support with concealment. Psychological distress was associated with enacted stigma and lower family support, but not with proximal stressors (sexual identity concerns and concealment). Alternative model testing found sexual identity acceptance concerns predicted psychological distress and mediated the associations of norm conformity and LGB family support with distress. Findings provide partial support for the minority stress model in a Chinese context and suggest the importance of incorporating cultural considerations into minority stress conceptualizations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026770PMC
October 2020

A more responsive, multi-pronged strategy is needed to strengthen HIV healthcare for men who have sex with men in a decentralized health system: qualitative insights of a case study in the Kenyan coast.

J Int AIDS Soc 2020 10;23 Suppl 6:e25597

Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.

Introduction: HIV healthcare services for men who have sex with men (MSM) in Kenya have not been openly provided because of persistent stigma and lack of healthcare capacity within Kenya's decentralized health sector. Building on an evaluation of a developed online MSM sensitivity training programme offered to East and South African healthcare providers, this study assessed views and responses to strengthen HIV healthcare services for MSM in Kenya.

Methods: The study was conducted between January and July 2017 in Kilifi County, coastal Kenya. Seventeen policymakers participated in an in-depth interview and 59 stakeholders, who were purposively selected from three key groups (i.e. healthcare providers, implementing partners and members of MSM-led community-based organizations) took part in eight focus group discussions. Discussions aimed to understand gaps in service provision to MSM from different perspectives, to identify potential misconceptions, and to explore opportunities to improve MSM HIV healthcare services. Interviews and focus group discussions were recorded, transcribed verbatim and analysed using Braun and Clarke's thematic analysis.

Results: Participants' responses revealed that all key groups navigated diverse challenges related to MSM HIV health services. Specific challenges included priority-setting by county government staff; preparedness of leadership and management on MSM HIV issues at the facility level; data reporting at the implementation level and advocacy for MSM health equity. Strong power inequities were observed between policy leadership, healthcare providers and MSM, with MSM feeling blamed for their sexual orientation. MSM agency, as expressed in their actions to access HIV services, was significantly constrained by county context, but can potentially be improved by political will, professional support and a human rights approach.

Conclusions: To strengthen HIV healthcare for MSM within a decentralized Kenyan health system, a more responsive, multi-pronged strategy adaptable and relevant to MSM's healthcare needs is required. Continued engagement with policy leadership, collaboration with health facilities, and partnerships with different community stakeholders are critical to improve HIV healthcare services for MSM.
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http://dx.doi.org/10.1002/jia2.25597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527756PMC
October 2020

A "tax" on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area.

Cult Health Sex 2020 Sep 14:1-16. Epub 2020 Sep 14.

Department of Behavior and Social Sciences, Brown University School of Public Health, Providence, RI, USA.

Many transgender (trans) young adults migrate to urban enclaves with known infrastructures to fulfil gender affirmation needs such as obtaining trans-inclusive healthcare and support. This study sought to explore experiences of intranational migration (i.e. migration within a single country) for gender affirmation among trans young adults who relocated to San Francisco. A convenience sample of 61 trans young adults aged 18 to 29 (32% nonbinary, 28% trans women, and 40% trans men; 84% identified as a person of colour) participated in a one-time qualitative interview as part of a larger study. Thematic analysis was used to develop and refine the codes and themes. Three overarching themes became apparent regarding intranational migration and gender affirmation needs: (1) access to basic gender affirmation needs; (2) safety; and (3) the price of gender affirmation. Migration for gender affirmation and safety placed informants at risk for structural vulnerabilities including homelessness, unemployment and racism. Despite these structural vulnerabilities, participants were willing to "pay" the price in order to gain gender affirmation and safety. Findings underscore the importance of moving beyond individual-level risk factors to understand how unmet gender affirmation needs may place trans young adults in structurally vulnerable positions that can affect health and wellness.
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http://dx.doi.org/10.1080/13691058.2020.1809711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7956137PMC
September 2020

A "tax" on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area.

Cult Health Sex 2020 Sep 14:1-16. Epub 2020 Sep 14.

Department of Behavior and Social Sciences, Brown University School of Public Health, Providence, RI, USA.

Many transgender (trans) young adults migrate to urban enclaves with known infrastructures to fulfil gender affirmation needs such as obtaining trans-inclusive healthcare and support. This study sought to explore experiences of intranational migration (i.e. migration within a single country) for gender affirmation among trans young adults who relocated to San Francisco. A convenience sample of 61 trans young adults aged 18 to 29 (32% nonbinary, 28% trans women, and 40% trans men; 84% identified as a person of colour) participated in a one-time qualitative interview as part of a larger study. Thematic analysis was used to develop and refine the codes and themes. Three overarching themes became apparent regarding intranational migration and gender affirmation needs: (1) access to basic gender affirmation needs; (2) safety; and (3) the price of gender affirmation. Migration for gender affirmation and safety placed informants at risk for structural vulnerabilities including homelessness, unemployment and racism. Despite these structural vulnerabilities, participants were willing to "pay" the price in order to gain gender affirmation and safety. Findings underscore the importance of moving beyond individual-level risk factors to understand how unmet gender affirmation needs may place trans young adults in structurally vulnerable positions that can affect health and wellness.
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http://dx.doi.org/10.1080/13691058.2020.1809711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7956137PMC
September 2020
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