VA Transgender Health Study

THE HEALTH, HEALTH RELATED NEEDS, AND LIFE COURSE EXPERIENCES OF TRANSGENDER VIRGINIANS Prepared by: Jessica Xavier, M.P.H. Julie A. Honnold, Ph.D. Judith Bradford, Ph.D. Community Health Research Initiative Center for Public Policy Virginia Commonwealth University For: Virginia HIV Community Planning Committee and Virginia Department of Health January 2007 Virginia Transgender Health Initiative Study Statewide Survey Report Executive Summary The Community Health Research Initiative (CHRI) of Virginia Commonwealth University conducted a statewide survey of transgender people living in Virginia as part of the Virginia Transgender Health Initiative Study (THIS). THIS, a multi-phase, multi-year project to improve the health of transgender Virginians, was implemented by CHRI under the direction of the Virginia Department of Health Division of Disease Prevention (VDH), advised by the Virginia HIV Community Planning Committee (VHCPC). The overall mission of the VHCPC, working with VDH under the guidance of the US Centers for Disease Control and Prevention, is to identify the most effective HIV prevention strategies for Virginia, including the development of a comprehensive plan and setting priorities for HIV/STD primary and secondary services in collaboration with consumers and providers. The quantitative component of THIS examines health care access by identifying the gaps in services needed by transgender people, in order to identify possible means to reduce risk behaviors in this population.  Data were gathered on access to regular medical care, transgender-related medical care, HIV prevention and treatment services; HIV knowledge, risk behaviors, testing and status; employment and housing discrimination; sexual and physical violence, social support and self esteem; substance abuse and tobacco use; and suicidal ideation and attempts. Psychosocial variables unique to transgender people were also assessed to examine how they influenced HIV and other risks in this population. Recruitment of participants was conducted by CHRI staff, a Transgender Task Force, and VHCPC members, who promoted participation in the survey through service providers, transgender support groups, and informal peer networks. The questionnaire was available in three versions: a web-based version in English and paper versions in English and Spanish. The quantitative survey was conducted from September 2005 to July 2006 with 387 respondents and a final analysis sample of 350, including 229 MTFs (male-to-females) and 121 FTMs (female-to-males). With participants from 60 of the 136 cities and counties in Virginia, THIS is the first truly statewide needs assessment survey of a transgender population in the U.S. FTM participants were much younger than MTF participants, with median ages of 28 and 40 years, respectively. FTM participants were somewhat better educated than their MTF peers, with 99% having graduated from high school, compared to 90% of MTFs. Nearly 81% of FTMs also reported attending some college, compared to 63% of the MTFs. MTFs reported higher individual and household annual incomes than FTMs. MTFs reported their gender identities mostly as transgender (49%) or women (31%), and FTMs identified mostly as men (37%) or transgender (28%). Forty-five percent of all participants had gender transitioned at the time of the survey, with FTMs having transitioned earlier than MTFs, at a median age of 23 and 28 years, respectively. Another third of participants were planning to transition within 3 years. Seventy-three percent of participants had health insurance, and 62% had a doctor they saw regularly for health care. Forty-six percent of all participants had to educate their regular doctors about their health care needs as a transgender person, including just over half of the FTMs. Slightly over half of participants felt they would be either uncomfortable or very uncomfortable discussing their transgender status or transgender-specific health care needs with a doctor they did not know, including two-thirds of FTMs. Twenty-four percent of participants had experienced discrimination by a doctor or other health care provider due to their transgender status or gender expression. Both MTF and FTM participants became aware at a median age of 10 years that their gender identities (their internal sense of their gender) did not match their bodies or physical appearances. FTMs sought treatment for their gender differences earlier than their MTF peers. Seventy-two percent had received counseling or psychotherapy, and 48% had received transgender hormonal therapy. However, participants reported that these services, along with transgender-related surgery, were also the most difficult to obtain. Across all transgender-related services, the most common barriers were inability to pay for the services, their health insurance plans not covering the service, and not knowing if the service was available in their area. Only a third of FTMs received transgender-sensitive gynecological care, and they rated it lower than MTFs for provider sensitivity. Twenty-eight percent of FTMs reported needing but not obtaining transgender-sensitive gynecological care. FTMs consistently rated the quality of care they received and their provider sensitivity lower than MTFs. Fifty-eight percent of all participants had taken either estrogen or testosterone for transgender related body transformation during their lifetimes, including nearly two-thirds of MTFs and 41% of FTMs. Forty-eight percent were taking hormones at the time of the survey. Among those not currently taking hormones and those who had never taken hormones, just over half (52%) were planning to take hormones in the future. Half of the hormone-experienced participants had obtained their hormones from someone other than a doctor (from friends, on the street or through the internet) including nearly 60% of MTFs and 22% of FTMs. Nearly 46% of the hormone-experienced had injected themselves with hormones or received a hormone injection from someone other than a doctor or nurse, including 71% of FTMs and 37% of the MTFs. Only six participants among the 90 who had injected themselves reported sharing syringes with others, including five MTFs and one FTM. Forty-two MTF participants (19%) and two FTM participants (2%) reported injection silicone use, with nine ISUs (21%) sharing needles. Nearly 13% of MTFs had undergone genital surgeries, and 22% of FTMs had undergone chest surgeries. Just 3% of FTMs underwent genital sex reassignment. One in five of the participants felt they had been denied a job due to their transgender status or gender expression, including 21% of MTFs and 18% of FTMs. Thirteen percent reported being fired from a job due to an employer’s reaction to their transgender status or gender expression, including 15% of MTFs and 9% of FTMs. A quarter of all participants reported being homeless at some point in their lives, including a third of FTMs and 20% of MTFs. Nine percent of participants, including 14% of FTMs and 6% of MTFs, reported losing housing or a housing opportunity due to their transgender status or gender expression. Twenty-seven percent reported they had been forced to engage in unwanted sexual activity since the time they were 13 years old, including 35% of FTMS and 22% of MTFs. Forty percent of the participants reported being physically attacked since the time they were 13 years old, including 45% of FTMs and 36% of MTFs. Nearly two-thirds of participants reported having thoughts of killing themselves in their lifetimes, including 79% of the FTMs and 58% of the MTFs. Among MTFs reporting suicidal ideation, 61% felt their gender issues were either most of or the main reason for their suicidal ideation, compared to 39% of FTMs. Among participants who reported suicidal ideation, 41% made suicide attempts, with similar attempt rates for MTFs and FTMs. On a lifetime basis, marijuana (67%), painkillers (42%), powder cocaine (32%), and downers (27%) were the most popular drugs used by participants. FTMs exhibited higher rates of lifetime use and earlier first use of drugs than the MTFs. On a lifetime basis, 6% of participants had injected drugs (not including hormones) including 8% of FTMs and 5% of MTFs. Among all IDUs, 8 (40%) reported sharing needles to inject their drugs. Participants reported much lower levels of their current drug use, with marijuana (18%), downers (5%), painkillers (5%), poppers (3%), and powder cocaine (3%) the most popular. Ninety-three percent of participants had drunk alcohol in their lifetimes, and a quarter of those felt it had been a problem, including 39% of FTMs and 18% of MTFs. Nearly two thirds of participants had used tobacco in their lifetimes, including 75% of the FTMs and 59% of the MTFs. Nearly 96% of the participants reported they had sex in their lifetimes, including 97% of MTFs and 94% of FTMs. Sixty-two percent of the MTFs had sex with non-transgender men, 61% with nontransgender women, 16% with other transgender women, and 8% with FTMs. Eighty-seven percent of the FTMs had sex with non-transgender women, 54% with non-transgender men, 18% with other FTMs, and 8% with transgender women. Eighty-four percent of FTMs and 72% of MTFs reported having sex in the past six months. Among the recently sexually active MTFs, 60% had sex with non-transgender men, 37% with non-transgender women, 8% with other MTFs, and 4% with FTMs in the past six months. Among the recently sexually active FTMs, 82% had sex with non-transgender women, 18% with nontransgender men, 11% with other FTMs, and 3% with MTFs in the past six months. Among the MTFs with primary partners, 50% never used condoms or other protective barriers, compared to 22% who always used them. Among the FTMs with primary partners, 51% never used condoms or other protective barriers, compared to nearly 19% who always used them. Among the MTFs with other partners besides their primary partner, 39% always used condoms or other protective barriers, and 10% rarely or never did. Among the FTMs with other partners, 53% always used condoms or other protective barriers, with 13% never using them. Twenty-four percent of participants were abstaining from sex at the time of the survey, including 28% of MTFs and 17% of FTMs. The most commonly reported sources of information about HIV and AIDS were participants’ doctor’s offices (42%), television, radio and magazines (40%), internet searches (39%), their peers (34%), and school (32%). Overall, FTMs scored higher in both their HIV knowledge and perception of HIV/AIDS risk. Two-thirds of participants had received printed HIV prevention and education materials, but they were rated the lowest among the four prevention and education services for quality and sensitivity to the participants as transgender persons. Twenty-eight percent of participants had encountered HIV outreach services, and 27% had attended an HIV prevention group or workshop. As with transgender care services, FTMs consistently ranked service quality and sensitivity lower than their MTF peers, especially in the sensitivity of providers towards them as transgender persons. Eighty-two percent of all participants had been tested for HIV, with 36% getting their most recent test less than six months ago and 58% within the past year. The most common reason given for not getting tested was always having safer sex (38%). Over a third of those tested had had unprotected sex since their last HIV test, including almost half of the FTMs and almost a third of MTFs. Among the 266 participants who reported their HIV status, 10.5% were HIV positive, nearly 86% were negative and 4% did not know their results. None of the tested FTMs who reported their HIV status was positive. Among the MTFs who reported their status, 16% (28 participants) were HIV positive. Most found out about their infections two or more years ago. The most commonly reported means of becoming infected was unprotected sex with a non-transgender man (86%). Among the HIV positive transgender women, 22 (79%) were taking HIV medications at the time of the survey. Of the 22 taking HIV medications, 10 (46%) were also taking transgender-related hormones with those HIV medications. The doctors of 9 of the 10 HIV+ transgender women knew they were taking hormones as well as HIV medications, and 7 had discussed possible interactions between their hormones and HIV medications. Among HIV treatment services, HIV medications were the most utilized service, followed by case management, CTR, support groups, ER visits, and outpatient care. The least utilized services were substance abuse treatment, transportation services and home health care. Among those services rated by 10 or more HIV+ participants, HIV-related emergency room visits was rated lowest for both quality and provider sensitivity. Reported barriers to HIV treatment were low, and only a few participants who had encountered a barrier to a treatment service reported a reason for being unable to obtain it. The most difficult HIV-related services to obtain were HIV-related financial assistance (by 7 participants) and HIV medications. Introduction Transgender people are those who cannot or choose not to conform to societal gender norms based upon their physical or birth sex. Their gender vector describes the direction of gender change from natal sex assignment and provides a basic means of their classification. Thus, transgender women are natal males with female identification or expression (male-to-females or MTFs), and transgender men are natal females with male identification or expression (female-to-males or FTMs). Transgender includes a variety of subpopulations, with many identity self-descriptors that can be hard to define. Transsexual people are transgender people who seek or who have undergone surgical sex reassignment. While nearly all transsexual people undergo gender transition and begin living in a gender opposite their physical sex, not all transgender subpopulations will do so. Following its similar studies of other at-risk groups, the Virginia HIV Community Planning Committee (VHCPC) chose transgender people as a population of special interest for research in 2002. At that time, transgender people living in Virginia were one of four populations of special interest with virtually no data to inform the VHCPC’s process in assisting the Virginia Department of Health with its HIV prevention planning for the Commonwealth. The Centers for Disease Control and Prevention (CDC) has classified transgender people as a “Special Population” within the Men who have Sex with Men category, regardless of their gender vector. As of this date, the CDC has not conducted separate surveillance assessment of the prevalence or incidence of HIV among transgender persons. However, there is sufficient data from studies conducted by other public health organizations suggesting that transgender people are at high risk for HIV infection. HIV prevalence among transgender women has been found to be very high, ranging from 14% in San Juan, PR (Rodríquez-Madera, & Toro-Alfonso, 2005); 19% in Philadelphia, PA (Kenagy, 2005); 21% in Chicago, IL (Kenagy & Bostwick, 2005); 22% in Los Angeles, CA (Simon, Reback, & Bemis, 2000); 22% in New York, NY (McGowan, 1999); 27% in Houston, TX (Risser, Shelton, McCurdy, Atkinson, Padgett, Useche, Thomas, & Williams, 2005); 32% in Washington, DC (Xavier, Bobbin, Singer & Budd, 2005) and 35% in San Francisco, CA (Clements-Nolle, Marx, Guzman, & Katz, 2001). Transgender women sex workers are at particularly high risk, since they are often financially induced to engage in barrier-free sex (Boles & Elifson, 1994; McGowan, 1999; Nemoto, Operario, Keatley, Han, & Soma, 2004). A 1993 study of 53 transgender women sex workers in Atlanta, GA found that 68% were HIV positive, 79% had syphilis, and 76% had hepatitis B (Elifson, Boles, Posey, Sweat, Darrow & Elsea, 1993). Although significantly under-examined, HIV prevalence among FTMs was found to be 3% in Washington, DC (Xavier et al, 2005) and 2% in San Francisco, CA (Clements-Nolle et al, 2001). High rates of substance abuse have been found by all the studies cited above, including injection drug use involving needle sharing among transgender women and men (Clements, Katz, & Marx, 1999; McGowan, 2000; Risser et al, 2005). Other often overlooked means of viral transmission of HIV and Hepatitis B and C include sharing of needles for the injection of hormones and the injection of silicone or other heavy liquids by transgender women or illicit providers to alter their bodyshapes. Among transgender women, injection silicone use has been found to range from 13% to 33% (Risser et al, 2005; Xavier et al, 2005; McGowan, 1999; Kenagy & Bostwick, 2005; Kenagy, 2005; and Reback, Simon, Bemis, & Gatson, 2001). In addition to the quantitative research cited above, a number of qualitative studies have examined the health care and social service needs of transgender people, in relation to their HIV, other STD and substance abuse risks (Boles & Elifson, 1994; Bockting, Robinson, & Rosser, 1998; Kammerer, Mason, Connors, & Durkee, 1999; Clements, Wilkinson, Kitano, & Marx, 1999; Nemoto, Operario, Keatley, & Villegas, 2004; and Sperber, Landers, & Lawrence, 2005). Taken together, these studies suggest that the social stigma of transgenderism produces extreme social marginalization, resulting in lives dominated by discrimination, violence, and multiple barriers to access to health care and social services. Transgender people are underserved not only in HIV prevention and treatment services, but also in access to medical care, especially transgender-related health care. ENTIRE REPORT