Background: A dearth of information surrounds the sexual partnerships of transgender masculine (TM) individuals, including whether characteristics of these partnerships are associated with STI-related sexual risk behavior. In this study, we sought to examine whether individual- and partnership-level factors of TM individuals’ sexual partnerships were associated with their use of a protective barrier during sexual activity. Methods: Data were collected from a cross-sectional survey administered to 150 TM participants at a community health clinic in Boston, Massachusetts. Participants provided demographic and sexual health information for up-to-three sexual partners from the past 12 months (n= 259 partnerships). Generalized estimating equations (GEEs) were used to calculate odds ratios and 95% Wald confidence intervals for protective barrier use for five sexual behaviors, including: 1) performing frontal and/or anal penetration with a finger/fist; 2) receiving frontal and/or anal penetration with a finger/fist; 3) performing oral-genital sex; 4) receiving oral-genital sex; and 5) having frontal receptive sex with genitals. Results: Participants were predominantly between the ages of 25-29 years (40.7%), white (75.2%), held a gender identity of “transgender man (FtM)” (48%), and identified their sexual orientation as “queer” (47.5%). Sexual partnerships were primarily with cisgender women (42.2%), followed by cisgender men (31.6%) and transgender/non-binary individuals (26.2%). Most partnerships were instances of casual sex (43%), followed by monogamous (35.6%) and non-monogamous relationships (21.5%). Individual-level factors associated with protective barrier use included age and race. Participants ages 21-24 years had lower odds of using a protective barrier while performing and receiving frontal and/or anal penetration with a finger/fist compared to participants ages 30-50 years [performing: OR=0.27 (0.09, 0.79); receiving: OR=0.20 (0.06, 0.66)]. Non-white participants had higher odds of using a protective barrier while receiving oral-genital sex compared to white participants [OR=3.08 (1.08, 8.82)]. At the partnership-level, factors associated with protective barrier use included the configuration of the sexual partnership and the assigned-sex-at-birth of the sexual partner. Participants in non-monogamous relationships had higher odds of protective barrier use while performing and receiving frontal and/or anal penetration with a finger/fist compared to those in monogamous relationships [performing: OR=4.25 (1.76, 10.27); receiving: OR=3.45 (1.18, 10.03)]. Participants with an assigned-male-at-birth partner had lower odds of using a protective barrier while receiving frontal and/or anal penetration with a finger/fist and while performing oral-genital sex compared to those with an assigned-female-at-birth partner [receiving fingering/fisting: OR=0.19 (0.07, 0.54); performing oral-genital: OR=3.09 (1.22, 7.79)]. Discussion: Both individual- and partnership-level factors of TM participants’ sexual partnerships were significantly associated with protective barrier use. These included the age and race of the participant, the configuration of the sexual partnership, and the assigned-sex-at-birth of the sexual partner. Statistical significance for associations between these factors and protective barrier use was behavior-specific. Findings may have implications for the development of population- and behavior-specific interventions to improve the sexual health of TM individuals and their sexual partners.

Background: Housing is well understood to be an important social determinant of physical and mental health and well-being. Transgender and gender non-binary people are more likely to experience homelessness and housing discrimination than their cisgender counterparts. Housing insecurity, not just homelessness, is associated with barriers to health care and increased use of acute-care services. This study explores homelessness and housing insecurity among gender minority individuals. Methods: Utilizing targeted ethnography, we conducted 41 semi-structured key-informant interviews with gender minority individuals throughout the USA. Interviews queried life stressors, particularly around homelessness and housing insecurity, and included personal experiences and community accounts, connections to other aspects of life such as employment and relationships, and coping strategies. Interviews were audio recorded and transcribed. Data was coded and analyzed for key themes using NVIVO 11. Results: Respondents discussed an array of housing challenges throughout the gender minority community. About half of respondents reported personal stories; the others frequently shared peer accounts of such housing challenges. Overwhelmingly, financial barriers were discussed regarding access to secure housing, although family rejection and gender-related housing discrimination were also discussed. Financial barriers focused on pervasive discrimination, which limited access to stable employment, cyclically furthering the limited access to stable housing. Discrimination stories were greater for non-white or trans-feminine respondents, leading to even more financial barriers and insecure housing for these populations. Housing insecurity was linked to hygiene and health challenges, overall stress, difficulty maintaining work, and food insecurity. Respondents discussed social support, alternative family structures, and substance use as coping resources. Conclusions: Nearly all respondents discussed housing challenges as an issue in the gender minority community and its link to other social wellbeing indicators, such as race-based discrimination and maintaining employment, which further destabilizes housing security. The study supports the increase of resources towards gender minority housing access and interventions that address the cyclical discrimination, housing, and employment issues this population faces.

Background: Increasing attention has recently centered on the school-to-prison pipeline (SPP), a set of mechanisms within the education system that funnel students into the criminal-legal system (CLS). Previous research has demonstrated that the SPP predominantly impacts Black youth and that racial discrimination and criminalization in schools contribute to higher rates of incarceration and other adverse CLS outcomes. Furthermore, research suggests that Black transgender women (TW) face disproportionate rates of adverse school outcomes (e.g. harassment, school discipline, dropout) and CLS outcomes (e.g. arrest, police harassment). Despite these documented disparities, literature examining the role of transgender discrimination in the SPP has been lacking. The purpose of this study was to assess the relationship between anti-transgender educational experiences and adverse CLS outcomes among Black TW. Methods: Data were derived from a survey (n=161) of TW in Atlanta and Chicago, which assessed stressors across the life course. Recruitment strategies included referral from LGBTQ organizations, posting flyers in venues frequented by TW, in-person recruitment at LGBTQ venues, use of a community recruiter, and snowball sampling. Eligibility criteria for the study were as follows: assigned male at birth; identify as a transgender woman and/or transfeminine; age 18 or older; and able to read/write in English. Black/African American race was used to classify the analytic subset for this study. Participants were screened and completed the survey in-person on university campuses in Atlanta and Chicago. Survey questions assessed sociodemographic characteristics, life stressors, and experiences with institutions including education and the CLS. Analyses included descriptive statistics and logistic regression. Results: Overall, 138 Black/African American TW participated in study and were included in our analytic sample. The mean age of the sample was 30.8 (range=18-65; SD=10.0) and the sample was mostly low-income with 81.3% reporting an annual income under $20,000. Anti-transgender experiences in education were common with 40.5% reporting experiencing anti-transgender victimization in school, 22.0% reporting being denied gender-appropriate facilities, and 7.9% reporting being expelled or denied enrollment due to being transgender. Additionally, 16.2% had not completed high school or a GED. Overall, 54.3% of the sample had ever been incarcerated, 55.8% reported experiencing anti-transgender mistreatment by police, and 26.1% reported discomfort seeking police assistance. Of those who reported previous incarceration, 65.3% were incarcerated for six months or less, 60.3% reported experiencing victimization while incarcerated, 34.2% reported being denied access to hormones, and 19.2% reported being denied access to regular medical care. Logistic regression revealed that anti-transgender school victimization was associated with greater odds of incarceration (p=.040, OR=2.24). Anti-transgender school expulsion/denial of enrollment (p=.044, OR=10.27) and denial of gender-appropriate facilities in school (p=.046, OR=3.75) were associated with greater odds of anti-transgender mistreatment by police. Discussion: Anti-transgender victimization, discrimination, and policies in school may have negative downstream impacts on Black TW's criminal-legal outcomes and thus warrant consideration in future investigations of the school-to-prison pipeline. Furthermore, interventions promoting transgender inclusivity in schools may improve CLS outcomes and the wellbeing of Black TW.

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Background: The Study of Transition, Outcomes & Gender (STRONG) was initiated to assess morbidity among transgender people in general and after gender affirming treatments at Kaiser Permanente health plans in Georgia and Northern and Southern California. The study included two components. The first component was a cohort study that collected data using electronic medical records (EMR) of transgender individuals enrolled in the participating plans. The second component was a survey of selected EMR cohort participants.
Methods: The EMR cohort was assembled based on a step-wise methodology involving computerized searches of electronic records and free text validation of eligibility and gender identity. The cohort included 3,475 (54%) transfeminine (TF), 2,892 (45%) transmasculine (TM) members; for only 89 (1%) participants gender identity was unknown. The cohort was matched to 127,608 enrollees with no transgender evidence (63,825 women and 63,783 men) on year of birth, race/ethnicity, study site, and membership year of the index date. A total of 2,136 survey invitations were sent to validated transgender adults; 697 subjects (33%) responded. The survey examined measures of quality of life by history and extent of gender affirmation. Most self-reported outcomes in the survey were ascertained with previously validated instruments.
Results: The STRONG cohort has now provided data for 6 separate publications addressing different aspects of transgender health. Notable associations in the TF cohort include elevated risk of venous thromboembolism and ischemic stroke following estrogen initiation. Another notable finding was the high prevalence of mental health conditions among transgender people, particularly children and adolescents. The prevalence estimates for suicidal ideation and self-inflicted injuries as recorded in the EMR were orders of magnitude higher in transgender children and adolescents than in matched reference groups of the same age. The EMR study also found that transgender people do not experience higher incidence of cancer overall. The survey component of the study demonstrated that transgender congruence, body image, and measures of anxiety and depression were significantly more favorable among persons who had more extensive gender affirmation treatment compared to those who received less treatment.
Conclusions and future directions: In view of our results, the existing recommendations for follow up of transgender patients may need to be revised. Especially worrisome are findings for suicidal ideation and self-inflicted injuries among children and adolescents. These data indicate that a child presenting as transgender to a health care provider needs to be urgently evaluated for possible life-threatening co-morbidities. While our survey should not be considered conclusive due to its cross-sectional design, it may inform the on-going debate about coverage for gender affirmation therapy. STRONG is well-positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Future analyses will focus on incidence of vascular, mental health, and metabolic conditions, as well as changes in laboratory-based endpoints (e.g., polycythemia and bone density), overall and in relation to gender affirmation therapy.