Publications by authors named "Walter Bockting"

72 Publications

Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Transgender and Gender Nonbinary Individuals Engaged in a Longitudinal Cohort Study.

J Homosex 2021 Mar 27;68(4):592-611. Epub 2021 Jan 27.

Department of Psychiatry, Columbia University Irving Medical Center , New York, New York, USA.

While the COVID-19 pandemic in the United States disproportionately impacts marginalized communities, no empiric US-based research has focused specifically on transgender and gender nonbinary (TGNB) people. We examined the pandemic's impact on an established longitudinal cohort of TGNB individuals ( = 208) by administering an online survey between March-June 2020. We used multivariable linear regression to examine reduced LGBTQ/TGNB community support and disruptions in gender-affirming health care as predictors of psychological distress during the pandemic. We found that the pandemic exacerbated ongoing mental health disparities for TGNB individuals. Furthermore, reduced LGBTQ/TGNB support was associated with increased psychological distress during the pandemic. Interruption and/or delay in gender-affirming health care was not associated with increased psychological distress during the pandemic. Special attention is needed to address the unique ways in which TGNB individuals were affected by the COVID-19 pandemic. This includes increasing access to LGBTQ/TGNB community support and addressing long-standing health disparities.
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http://dx.doi.org/10.1080/00918369.2020.1868185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887093PMC
March 2021

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey.

Drug Alcohol Depend 2021 02 21;219:108474. Epub 2020 Dec 21.

Columbia University Irving Medical Center, 622 W. 168(th) Street, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA. Electronic address:

Background: Prescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population.

Methods: Data for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse.

Results: PD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021-1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133-1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354-1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255-1.534; AMAB OR = 1.227, 95 %CI 1.073-1.404).

Conclusion: In this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856161PMC
February 2021

Response to the Letter to the Editor on Perspective on Promoting Centers for Transgender Care.

J Oral Maxillofac Surg 2021 01 18;79(1). Epub 2020 Oct 18.

Cheshire, CT; Farmington, CT, North Haven, CT.

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http://dx.doi.org/10.1016/j.joms.2020.09.028DOI Listing
January 2021

Behavioral and neurobiological effects of GnRH agonist treatment in mice-potential implications for puberty suppression in transgender individuals.

Neuropsychopharmacology 2021 04 12;46(5):882-890. Epub 2020 Sep 12.

Division of Systems Neuroscience, Research Foundation for Mental Hygiene, Inc. (RFMH)/New York State Psychiatric Institute (NYSPI), New York, NY, 10032, USA.

In the United States, ~1.4 million individuals identify as transgender. Many transgender adolescents experience gender dysphoria related to incongruence between their gender identity and sex assigned at birth. This dysphoria may worsen as puberty progresses. Puberty suppression by gonadotropin-releasing hormone agonists (GnRHa), such as leuprolide, can help alleviate gender dysphoria and provide additional time before irreversible changes in secondary sex characteristics may be initiated through feminizing or masculinizing hormone therapy congruent with the adolescent's gender experience. However, the effects of GnRH agonists on brain function and mental health are not well understood. Here, we investigated the effects of leuprolide on reproductive function, social and affective behavior, cognition, and brain activity in a rodent model. Six-week-old male and female C57BL/6J mice were injected daily with saline or leuprolide (20 μg) for 6 weeks and tested in several behavioral assays. We found that leuprolide increases hyperlocomotion, changes social preference, and increases neuroendocrine stress responses in male mice, while the same treatment increases hyponeophagia and despair-like behavior in females. Neuronal hyperactivity was found in the dentate gyrus (DG) of leuprolide-treated females, but not males, consistent with the elevation in hyponeophagia and despair-like behavior in females. These data show for the first time that GnRH agonist treatment after puberty onset exerts sex-specific effects on social- and affective behavior, stress regulation, and neural activity. Investigating the behavioral and neurobiological effects of GnRH agonists in mice will be important to better guide the investigation of potential consequences of this treatment for youth experiencing gender dysphoria.
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http://dx.doi.org/10.1038/s41386-020-00826-1DOI Listing
April 2021

Promoting Centers for Transgender Care.

J Oral Maxillofac Surg 2020 11 10;78(11):1875-1877. Epub 2020 Jul 10.

Director, Beau Visage Med Spa and Greater Waterbury OMS, Cheshire, CT; and Associate Clinical Professor, Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT. Electronic address:

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http://dx.doi.org/10.1016/j.joms.2020.06.038DOI Listing
November 2020

Sociopolitical change and transgender people's perceptions of vulnerability and resilience.

Sex Res Social Policy 2020 Mar 19;17(1):162-174. Epub 2019 Feb 19.

New York State Psychiatric Insititute and Columbia University Medical Center.

Background: Transgender and gender nonconforming (TGNC) people have gained visibility in public discourse leading to greater awareness, understanding, and social change. However, progress made in policies to combat stigma and improve public accommodation and healthcare for this minority population have been targeted for reversal, particularly since the 2016 presidential election. This study investigated the impact of changes in sociopolitical climate on perceptions of vulnerability and resilience among participants of a longitudinal study of transgender identity development.

Methods: We randomly selected 19 TGNC participants in New York, San Francisco, and Atlanta, and conducted in-depth interviews about their perceptions of societal progress and setbacks, community engagement, and desired future change. Participants ranged in age from 18 to 68; half (47.4%) identified their gender identity along the feminine spectrum (male assigned at birth) and the other half (52.6%) along the masculine spectrum (female assigned at birth).

Results: Content analysis revealed that greater media visibility was perceived as both positive (improved awareness of needs) and negative (increased vulnerability to stigma). Setbacks included concerns about personal safety, the safety of others (particularly those with multiple stigmatized identities), healthcare access, and policies regarding public accommodation and nondiscrimination protections. Coping strategies included social support, activism and resistance, and an enduring sense of optimism about the future.

Conclusion: TGNC Americans, in spite of a long history of adversity, are resilient. Participants demonstrated unwavering motivation to create a better future for themselves, other minorities, and society. Research is needed to quantify the impact of policy changes on health and wellbeing, and identify moderators of resilience amenable to intervention.
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http://dx.doi.org/10.1007/s13178-019-00381-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394469PMC
March 2020

Stigmatization, Resilience, and Mental Health Among a Diverse Community Sample of Transgender and Gender Nonbinary Individuals in the U.S.

Arch Sex Behav 2020 10 23;49(7):2649-2660. Epub 2020 Jun 23.

Program for the Study of LGBT Health, New York State Psychiatric Institute, Columbia Psychiatry with the Columbia University School of Nursing, 722 W 168th Street, 3rd Floor, New York, NY, 10032, USA.

Transgender and gender nonbinary (TGNB) individuals were recently designated a health disparity population by the U.S. National Institutes of Health. We examined the effect of gender-related discrimination and resilience factors on the mental health of a community sample diverse in gender identity, age, and race/ethnicity. We report on the baseline data of a longitudinal study of transgender identity development across the lifespan with 330 TGNB individuals recruited through venue-based recruitment in three major metropolitan areas in the U.S. Mean age of participants was 34.4 years (SD = 13.7). Structured interviews collected self-report data on sociodemographics, gender-related discrimination, mental health, and resilience. We used hierarchical regression to examine the association between gender-related discrimination and psychological distress (BSI-18) and tested the moderating effect of family support, transgender community connectedness, gender literacy, and transgender activism on this relationship. In adjusted analyses, gender-related discrimination was positively associated with psychological distress. Family support was negatively associated with psychological distress. Contrary to our expectations, gender literacy and transgender activism were positively associated with psychological distress, while no significant relationship was found for transgender community connectedness. Family support, transgender community connectedness, gender literacy, and transgender activism did not moderate the effect of gender-related discrimination on psychological distress. Future mental health interventions should consider leveraging family support among TGNB individuals. Longitudinal studies are needed to better understand the role of gender literacy and activism with respect to mental health and development of identity and resilience among TGNB people.
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http://dx.doi.org/10.1007/s10508-020-01761-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494648PMC
October 2020

Trans adolescents' perceptions and experiences of their parents' supportive and rejecting behaviors.

J Couns Psychol 2020 Mar;67(2):156-170

Program for the Study of LGBT Health, New York State Psychiatric Institute/Columbia Psychiatry.

Transgender (trans) adolescents consistently report higher rates of adverse mental health outcomes compared to their cisgender peers. Parental support is a recognized adolescent protective factor; however, little is known about the specific parental behaviors that trans adolescents perceive as most or least supportive. To address this gap, we analyzed data from qualitative interviews conducted with an ethnically diverse, urban-based sample of trans adolescents (N = 24; 16-20 years old) to describe (a) the spectrum of specific parental behaviors across 3 categories-rejecting, supportive, and mixed (i.e., simultaneous supportive and rejecting behaviors)-and (b) the perceived psychosocial consequences across these 3 categories of parental behaviors. Qualitative data were gathered through lifeline interviews (i.e., visual representations from birth to present) and photo elicitation (i.e., photographs representing parental support and/or rejection). Supportive behaviors included instances where parents made independent efforts to learn about trans issues or help their child obtain gender-affirming health care. Rejecting behaviors included instances when parents refused to use their child's name or pronouns or failed to show empathy when their child struggled with gender-identity-related challenges. Mixed behaviors included examples when parents expressed support of their child's gender identity, but not of their sexual orientation (or vice versa). Overall, participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing. These findings expand upon descriptions of parental support and rejection within the trans adolescent literature and can help practitioners target specific behaviors for interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000419DOI Listing
March 2020

The Transgender Identity Survey: A Measure of Internalized Transphobia.

LGBT Health 2020 01 24;7(1):15-27. Epub 2019 Dec 24.

Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota.

We describe the development of a measure of internalized transphobia, defined as discomfort with one's transgender identity as a result of internalizing society's normative gender expectations. An item pool was created based on responses from a small clinical sample ( = 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18-72, mean [] = 37.4, standard deviation [] = 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18-66,  = 31.6,  = 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample. EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test-retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity. Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people's health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.
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http://dx.doi.org/10.1089/lgbt.2018.0265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6983734PMC
January 2020

Engagement and Retention in HIV Care for Transgender Women: Perspectives of Medical and Social Service Providers in New York City.

AIDS Patient Care STDS 2020 01 17;34(1):16-26. Epub 2019 Dec 17.

HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality, and Health, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, New York.

Transgender women are less likely to engage in HIV care and adhere to antiretroviral medications than other at-risk populations. Health care and social service providers, in addition to consumers, have experiences that can elucidate barriers and facilitators to care and inform interventions. Guided by the social/ecological model, we conducted interviews with 19 providers working with transgender women. At the health systems level, perceived barriers included lack of care accessibility and security, providers' misunderstanding of the transgender community, and lack of cultural competency of information systems and staff. At the community level, barriers included HIV stigma. At the family level, barriers included rejection and housing instability. At the individual level, barriers included conflicts between HIV- and transgender care, medication side effects, competing priorities, mental health issues and substance abuse, and low health literacy. Facilitators included provider competence in transgender health, improved access to care, and patient empowerment. Findings indicate the need for an integrated care model.
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http://dx.doi.org/10.1089/apc.2019.0067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6983737PMC
January 2020

Assessing Sexual Orientation and Gender Identity in Home Health Care: Perceptions and Attitudes of Nurses.

LGBT Health 2019 Nov/Dec;6(8):409-416

School of Nursing, Columbia University, New York, New York.

The purpose of this study was to explore home health care nurses' attitudes, perceptions, and experiences related to routine collection and documentation of sexual orientation and gender identity data. This was a qualitative descriptive study. Twenty-four nurses from a large home health care agency in the New York metropolitan area were interviewed between November 2014 and December 2015. Three broad categories of themes emerged from the content analysis: (1) current practices that relate to or influence the assessment of sexual orientation or gender identity by home health care nurses, (2) attitudes and perceptions regarding perceived barriers and facilitators to discussing and documenting sexual orientation and gender identity, and (3) training and resources identified as helpful in preparing nurses to discuss sexual orientation and gender identity with their patients. Nurses emphasized wanting to provide everyone with the same quality of care and wanted documentation to inform the care. They felt unprepared to discuss sexual orientation or gender identity with their patients and indicated a need for training and education related to LGBT health disparities. Results from this study can help inform the development of training materials and resources to enable nurses to collect patients' sexual orientation and gender identity data routinely and in a sensitive and culturally competent manner.
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http://dx.doi.org/10.1089/lgbt.2019.0030DOI Listing
September 2020

"Just Like Any Other Patient": Transgender Stigma among Physicians in Puerto Rico.

J Health Care Poor Underserved 2019 ;30(4):1518-1542

Background: Transgender women (TW) in Puerto Rico (PR) face social stigmatization. Physicians' transgender stigma can have detrimental consequences for TW's health.

Purpose: The objective of this study was to document physicians' knowledge, competencies, and attitudes towards TW in PR and study their associations with stigma towards TW.

Methods: We implemented an exploratory sequential mixed-methods study. We used in-depth interviews (n=30) and self-administered questionnaire (n=255).

Results: Qualitative results illustrated lack of recognition of the needs of TW; they also evidenced the impact of stigmatizing attitudes on clinical decisions. Quantitative results showed that more willingness and knowledge to provide health services to TW were negatively associated with stigma. Participants who reported history of training in working with TW presented significantly less stigma than participants who had not received such training.

Conclusion: In order to provide stigma-free services for TW in PR, specialized training regarding the particular needs of this population is needed.
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http://dx.doi.org/10.1353/hpu.2019.0089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233420PMC
July 2020

Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs).

AIDS Behav 2020 May;24(5):1452-1462

Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA.

There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.
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http://dx.doi.org/10.1007/s10461-019-02703-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181384PMC
May 2020

Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs).

AIDS Behav 2020 May;24(5):1452-1462

Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA.

There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.
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http://dx.doi.org/10.1007/s10461-019-02703-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181384PMC
May 2020

Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS.

J Behav Med 2020 04 26;43(2):329-338. Epub 2019 Sep 26.

Program for the Study of LGBT Health, Columbia University School of Nursing, 560 West 168th Street, New York, NY, 10032, USA.

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.
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http://dx.doi.org/10.1007/s10865-019-00102-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899707PMC
April 2020

Knowledge About Oral PrEP Among Transgender Women in New York City.

AIDS Behav 2019 Oct;23(10):2779-2783

Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA.

This paper grows our understanding about PrEP knowledge in transgender women (TW) to improve PrEP-focused education/outreach. Research took place in New York City. We conducted four focus groups in English or Spanish (N = 18). Discussions focused on participants' perceptions and knowledge of oral PrEP. Most participants knew that PrEP is efficacious and requires consistent use. However, some participants were skeptical of medications; others acknowledged that false assumptions about PrEP exist among TW. Most TW in our focus groups were informed about PrEP through clinics or community-based organizations. Some participants felt that messages about medications were oversimplified, and wanted more information.
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http://dx.doi.org/10.1007/s10461-019-02584-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790168PMC
October 2019

Invalidation Experiences Among Non-Binary Adolescents.

J Sex Res 2020 02 9;57(2):222-233. Epub 2019 May 9.

Program for the Study of LGBT Health, New York State Psychiatric Institute/Columbia Psychiatry and Nursing.

Mental health disparities among transgender adolescents are well documented and have generally been attributed to minority stress. However, significantly less is known about the minority stress experiences of non-binary adolescents or those who do not identify as exclusively male or female. This study qualitatively explored the unique ways that non-binary adolescents experience minority stress and how it influences their mental health and well-being. Lifeline methodology and photo elicitation were used to interview 14 ethnically diverse non-binary adolescents between the ages of 16 and 20, residing in New York City (NYC) and the San Franscicso Bay Area (SFBA). We present participants' experiences using a novel construct of defined as the refusal to accept one's identity as real or true. Our findings indicate that invalidation is conceptually distinct from the established minority stressor of "non-affirmation." Non-binary adolescents experienced myriad forms of invalidation within multiple social contexts, which contributed to negative affective and cognitive processes, including confusion, self-doubt, rumination, and internalized shame. For many participants, the cumulative stressors related to invalidation contributed to poor mental health outcomes. Data from this study suggest that identity invalidation is a unique form of minority stress that may especially affect non-binary individuals, with significant implications for their social and emotional well-being.
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http://dx.doi.org/10.1080/00224499.2019.1608422DOI Listing
February 2020

How Far Has Transgender Health Come Since Stonewall?

Authors:
Walter Bockting

Am J Public Health 2019 06;109(6):852-853

Walter Bockting is with Columbia University and the New York State Psychiatric Institute, New York, NY.

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http://dx.doi.org/10.2105/AJPH.2019.305095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6508006PMC
June 2019

Understanding predictors of improvement in risky drinking in a U.S. multi-site, longitudinal cohort study of transgender individuals: Implications for culturally-tailored prevention and treatment efforts.

Addict Behav 2019 09 3;96:68-75. Epub 2019 May 3.

Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032, United States of America; New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America; Columbia University School of Nursing, 560 W. 168th Street, New York, NY 10032, United States of America. Electronic address:

Objective: While transgender people report higher rates of risky drinking than the general population, no studies have examined transgender alcohol use longitudinally. This study investigated minority stress and identity development predictors of improvement in risky drinking among transgender individuals.

Methods: Data come from a multi-site, longitudinal cohort study of U.S. transgender individuals (N = 330) and include measures of enacted stigma, felt stigma, identity development, and risky alcohol use. Theory-driven, hierarchical multivariable logistic regression was used to investigate the hypothesis that minority stress and identity development factors are related to improvement in risky drinking between baseline and 1-year follow-up.

Results: Baseline risky drinkers (n = 106; 37.1%) were younger and more likely to have female sex assigned at birth. At 1-year follow-up, 68 baseline risky drinkers (64.2%) reported persistent risky drinking, while 38 (35.8%) reported improved drinking. Controlling for demographics and study site, female sex assigned at birth and enacted stigma were associated with lower odds of improved drinking. Non-white/Hispanic race/ethnicity, felt stigma, change in gender role/expression for 1-5 years, and diffuse-avoidant identity style were associated with higher odds of improvement.

Conclusions/importance: This is the first study to identity predictors of improvement in risky drinking among transgender individuals. Compared to trans-feminine individuals (assigned male at birth), trans-masculine individuals (assigned female at birth) were more likely to report risky drinking at baseline and had lower odds of improvement at 1-year follow-up. Improved drinking may be facilitated by preventing anti-transgender discrimination. Felt stigma and diffuse-avoidant identity style may lower alcohol risk via avoidance of drinking venues. Further research is needed to explicate these relationships and to inform culturally-tailored alcohol interventions for this at-risk population.
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http://dx.doi.org/10.1016/j.addbeh.2019.04.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6571154PMC
September 2019

Exploring new and existing PrEP modalities among female sex workers and women who inject drugs in a U.S. city.

AIDS Care 2019 10 1;31(10):1207-1213. Epub 2019 Mar 1.

a Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.

To address a shortage in research on Pre-Exposure Prophylaxis (PrEP) amongst women at high risk of HIV acquisition, this study explored the attitudes and preferences of female sex workers (FSW) ( = 15) and women who inject drugs (WWID) ( = 16) to existing (e.g., pill) and new (e.g., injection, implant) PrEP modalities, in Baltimore, Maryland, U.S.A. This study reports on seven focus groups conducted between December 2016 and April 2017 and aims to provide new insights into FSW and WWID attitudes and preferences towards three different PrEP delivery methods (i.e., PrEP pill, PrEP implant, PrEP injection). Results draw upon the PrEP care continuum framework and distill existing factors, including lack of control over side effects with new, longer lasting modalities, better privacy with injections, increased adherence with reduced dosing schedules from longer lasting PrEP and new factors such as perceptibility concerns with respect to the PrEP implant relevant to PrEP uptake and adherence among two important overlapping, at-risk populations. The study contributes to a better understanding of barriers and facilitators to uptake and adherence for FSW and WWID around both existing and new PrEP modalities, with implications for future clinical trials and PrEP interventions with at risk-populations.
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http://dx.doi.org/10.1080/09540121.2019.1587352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663578PMC
October 2019

Nurse Documentation of Sexual Orientation and Gender Identity in Home Healthcare: A Text Mining Study.

Comput Inform Nurs 2019 Apr;37(4):213-221

Author Affiliations: Columbia University School of Nursing, New York, NY (Drs Bjarnadottir, Bockting, Yoon, and Dowding); University of Florida, College of Nursing, Gainesville (Dr Bjarnadottir); Program for the Study of LGBT Health, New York Psychiatric Institute/Columbia Psychiatry (Dr Bockting); Medicine Department, Division of General Medicine, Columbia University (Dr Yoon); Center for Home Care Policy & Research (Dr Dowding); and Visiting Nurse Service of New York (Dr Dowding), New York, NY; and Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, United Kingdom (Dr Dowding).

Health disparities have been documented in the lesbian, gay, bisexual, and transgender population, but more research is needed to better understand how to address them. To that end, this observational study examined what is documented about sexual orientation and gender identity in narrative home care nurses' notes in an electronic health record. Lexical text mining approaches were used to examine a total of 862 715 clinical notes from 20 447 unique patients who received services from a large home care agency in Manhattan, New York, and extracted notes were qualitatively reviewed to build a lexicon of terms for use in future research. Forty-two notes, representing 35 unique patients, were identified as containing documentation of the patient's sexual orientation or gender identity. Documentation of sexual orientation or gender identity was relatively infrequent, compared to the estimated frequency of lesbian, gay, bisexual, and transgender people in the US population. Issues related to fragmentary language emerged, and variety in phrasing and word frequency was identified between different types of notes and between providers. This study provides insight into what nurses in home healthcare document about sexual orientation and gender identity and their clinical priorities related to such documentation, and provides a lexicon for use in further research in the home care setting.
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http://dx.doi.org/10.1097/CIN.0000000000000492DOI Listing
April 2019

The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health.

LGBT Health 2018 10;5(7):401-411

2 New York State Psychiatric Institute , New York, New York.

Purpose: Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition.

Methods: Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma.

Results: Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status.

Conclusion: In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.
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http://dx.doi.org/10.1089/lgbt.2018.0103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207148PMC
October 2018

The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health.

LGBT Health 2018 10;5(7):401-411

2 New York State Psychiatric Institute , New York, New York.

Purpose: Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition.

Methods: Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma.

Results: Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status.

Conclusion: In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.
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http://dx.doi.org/10.1089/lgbt.2018.0103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207148PMC
October 2018

The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health.

LGBT Health 2018 10;5(7):401-411

2 New York State Psychiatric Institute , New York, New York.

Purpose: Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition.

Methods: Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma.

Results: Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status.

Conclusion: In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.
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http://dx.doi.org/10.1089/lgbt.2018.0103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207148PMC
October 2018

Mental Health Promotion for Gender Minority Adolescents.

J Psychosoc Nurs Ment Health Serv 2018 Dec 20;56(12):22-30. Epub 2018 Jun 20.

The current study uses an ecological model of biopsychosocial vulnerability to guide the description of risk and protective factors for the mental health of gender minority (i.e., transgender and gender non-conforming) adolescents at the individual, family, community, and societal levels. Minority stress is the vulnerability of youth who are lesbian, gay, bisexual, and transgender (LGBT) to adverse mental health outcomes due to stigma. In addition, unlike cisgender (non-transgender) LGB individuals, gender minorities may experience internal stress related to gender dysphoria. Gender dysphoria may lead to interaction with health care providers who may not be educated in the care of gender minority youth. The ecological model is an organizing framework for understanding domains of health risks that affect such youth to assist nurses in intervening to promote the health of gender minority adolescents. Specific attention is paid to the potential contributions of psychiatric-mental health nurses to the care of gender minority adolescents. [Journal of Psychosocial Nursing and Mental Health Services, 56(12), 22-30.].
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http://dx.doi.org/10.3928/02793695-20180601-02DOI Listing
December 2018

Healthcare Experiences Among Young Adults Who Identify as Genderqueer or Nonbinary.

LGBT Health 2018 04;5(3):191-196

3 Program for the Study of LGBT Health, New York State Psychiatric Institute/Columbia University , New York, New York.

Purpose: Research on healthcare among gender-diverse populations has largely focused on people who describe their gender in binary terms, either as trans men or trans women. This qualitative study examined the healthcare experiences of young adults who identify as genderqueer or nonbinary (GQ/NB).

Methods: Participants (N = 10) were interviewed about experiences seeking and accessing healthcare. All were young adults (ages 23-33) in the San Francisco Bay area who had accessed healthcare at least once in the prior 6 months. A semistructured interview guide elicited conversations about gender identity and experiences of healthcare. Interview transcripts were analyzed using emergent coding analysis to identify themes.

Results: Participants faced unique challenges even at clinics specializing in gender-affirming healthcare. They felt misunderstood by providers who approached them from a binary transgender perspective and consequently often did not receive care sensitive to nonbinary identities. In response to this perceived bias, participants sometimes "borrowed" a binary transgender label to receive care, modified the healthcare they were prescribed, or went without healthcare. The GQ/NB young adults in our study regularly felt disrespected and frustrated as they sought and accessed healthcare. Participants felt that the binary transgender narrative pressured them to conform to binary medical narratives throughout healthcare interactions.

Conclusions: GQ/NB young adults have unique healthcare needs but often do not feel understood by their providers. There is a need for existing healthcare systems to serve GQ/NB young adults more effectively.
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http://dx.doi.org/10.1089/lgbt.2017.0215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016091PMC
April 2018

Barriers and Facilitators to Oral PrEP Use Among Transgender Women in New York City.

AIDS Behav 2018 Nov;22(11):3627-3636

HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr, New York, NY, 10032, USA.

Transgender women may face a disparate risk for HIV/AIDS compared to other groups. In 2012, Truvada was approved for daily use as HIV pre-exposure prophylaxis (PrEP). However, there is a dearth of research about barriers and facilitators to PrEP in transgender women. This paper will shed light on transgender women living in New York City's perceived and actual challenges to using PrEP and potential strategies to overcome them. After completing an initial screening process, four 90-min focus groups were completed with n = 18 transgender women. Participants were asked what they like and dislike about PrEP. Participants identified the following barriers: uncomfortable side effects, difficulty taking pills, stigma, exclusion of transgender women in advertising, and lack of research on transgender women and PrEP. Facilitators included: reducing pill size, increasing the types of available HIV prevention products, and conducting scientific studies to evaluate PrEP in transgender women.
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http://dx.doi.org/10.1007/s10461-018-2102-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6160363PMC
November 2018

EXPLORING THE FEASIBILITY AND ACCEPTABILITY OF BIOMARKER COLLECTION FOR HIV INFECTION AND CHRONIC STRESS AMONG TRANSWOMEN IN PUERTO RICO.

Rev Puertorriquena Psicol 2017 Jul-Dec;28(2):268-281

New York State Psychiatric Institute / Columbia Psychiatry and the Columbia University School of Nursing.

The assessment of biomarkers related to HIV and chronic stress increases opportunities for the design of more comprehensive research and intervention efforts on the health of transwomen within the context of Health Psychology. In this paper, we present data from a study implemented in Puerto Rico that aimed to: document the feasibility/acceptability of collecting biomarkers for chronic stress and HIV among transwomen; qualitatively document the factors related to the collection of biomarkers in this population; and explore the feasibility of collecting other types of biological specimens from transwomen in future studies. We implemented an exploratory mixed-method study with a sample of 10 transwomen. Quantitative information was gathered via saliva and hair biomarkers for chronic stress and HIV, while qualitative data was obtained via in-depth interviews. Twenty percent had positive results for HIV antibodies and 30% had hair cortisol levels that exceeded the normal range. The main motivations behind the provision of biomarkers were the desire to know about their health; contributing to a better understanding of health in the transgender community; and having previous positive experiences with our research team. We discuss the incorporation of biomarkers as powerful tools to better describe and understand the health of transwomen.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751930PMC
January 2018

Generational Differences in Internalized Transnegativity and Psychological Distress Among Feminine Spectrum Transgender People.

LGBT Health 2018 01 3;5(1):54-60. Epub 2017 Nov 3.

1 School of Nursing, Program for the Study of LGBT Health, Columbia University , New York, New York.

Purpose: This study examined internalized transnegativity and psychological distress in two age groups of transgender individuals who identified their gender identity on the feminine spectrum (rather than congruent with their male sex assigned at birth). Due to greater visibility and acceptance of gender diversity in the United States, we hypothesized that internalized transnegativity would be lower in the younger compared with the older group, and that the younger generation would, therefore, report lower levels of psychological distress than the older generation.

Methods: The study sample consisted of trans-feminine individuals (N = 440) who completed a online survey of the U.S. transgender population and comprised a younger group aged 18-24 years (n = 133) and an older group aged 40 years and older (n = 307). Internalized transnegativity was assessed using the Transgender Identity Survey, and psychological distress was assessed with the Brief Symptom Inventory 18. We used regression and mediation analysis to examine differences between the two groups.

Results: Contrary to our expectations, the older group reported significantly lower levels of both internalized transnegativity and psychological distress compared with the younger group. Internalized transnegativity partially mediated the relationship between age group and psychological distress.

Conclusion: Despite greater visibility of transgender people and increasing acceptance of gender diversity in the United States, the younger trans-feminine individuals reported more psychological distress than the older transfeminine individuals, which was, in part, related to internalized transnegativity. Trans-feminine individuals may benefit from culturally sensitive and clinically competent mental health services to alleviate internalized transnegativity and psychological distress.
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http://dx.doi.org/10.1089/lgbt.2017.0034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770087PMC
January 2018

Demographic Characteristics, Components of Sexuality and Gender, and Minority Stress and Their Associations to Excessive Alcohol, Cannabis, and Illicit (Noncannabis) Drug Use Among a Large Sample of Transgender People in the United States.

J Prim Prev 2017 Aug;38(4):419-445

Division of Gender, Sexuality, and Health, New York State Psychiatric Institute, Columbia University, New York City, NY, USA.

The current study examined demographics, sexual orientation, gender characteristics, and gender minority stress and their association to excessive alcohol, cannabis, and illicit (noncannabis) drug use among 1210 transgender adults living in the United States. The authors conducted a secondary analysis of data that included 680 transgender women (M  = 32.63, SD  = 12.29) and 530 transgender men (M  = 26.14, SD  = 7.42). A modified version of the Risk Behavioral Assessment quantified participants' alcohol, cannabis, and illicit drug use in the past 3 months. Overall, 21.5% of participants reported excessive alcohol use; no significant differences were found on the rates of excessive alcohol use between transgender women and men. Cannabis use among our sample was 24.4%; trangender men reported significantly higher rates of cannabis use compared to transgender women. Illicit drug (noncannabis) use among our sample was 11.6%; transgender men also reported significantly higher rates of illicit drug use compared to transgender women. Multivariate analyses suggested that gender dysphoria was significantly associated with: excessive alcohol use for transgender women, cannabis use among both transgender women and men, and illicit (noncannabis) drug use among transgender women. A nonheterosexual orientation was associated with increased odds of cannabis use among transgender women and men; a nonheterosexual orientation was associated with greater odds of illicit substance use among transgender men but not among transgender women. Gender minority stressors were independently associated with excessive alcohol use among transgender men and cannabis use among transgender women. The authors suggest that minority stress may only partially account for substance use among transgender people. Consequently, the authors suggest that in addition to minority stress, other biopsychosocial mechanisms should continue to be examined to identify pathways that may lead to the development of effective substance use prevention efforts and treatment programs.
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http://dx.doi.org/10.1007/s10935-017-0469-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516932PMC
August 2017