OBJECTIVES:Sexual and gender minority (SGM) communities at increased risk of human immunodeficiency virus (HIV) may be underprescribed preexposure prophylaxis (PrEP), but PrEP research on SGM communities other than transgender women and cisgender men who have sex with men is limited. We sought to better understand SGM individuals' vulnerability to HIV acquisition and awareness and perceptions of PrEP in North Carolina, with a focus on SGM groups less often included in research. METHODS:We administered a 37-item online survey to adult SGM participants, examining differences in perceived and behavioral HIV risk based on self-reported behaviors. We also compared PrEP awareness, prescriptions, and stigma between SGM identities and used logistic regression to examine associations between HIV risk and PrEP use. RESULTS:In total, 372 participants completed the survey. Although 30.9% reported behaviors that increase the likelihood of HIV acquisition, only 9.5% perceived their risk as elevated. Most (78.5%) were aware of PrEP, but only 15.1% had been prescribed PrEP. PrEP stigma was most pervasive among cisgender women. Nonbinary and queer participants were more likely to have experienced mistreatment by a provider (20.3%, P < 0.0001; 19.2%, P < 0.01) and avoid care fearing mistreatment (31.9%, P < 0.001; 27.7%; P < 0.001) compared with the entire sample. CONCLUSIONS:PrEP is prescribed at low rates across many SGM communities, with misperception of HIV risk, PrEP stigma, and mistreatment in health care identified as important barriers. Healthcare providers should take steps to create a safe environment for SGM patients and ask all patients about HIV risk factors and provide information about PrEP regardless of sexual orientation or gender identity.

OBJECTIVE:To describe the lifetime prevalence of workplace harassment, physical violence and sexual assault against transgender and non-binary workers targeted due to their gender identity and to identify correlates of this workplace violence. METHODS:This descriptive cross-sectional study used data from 4597 transgender or non-binary respondents from the 2008-2009 National Transgender Discrimination Survey. Respondents reported if they had ever experienced harassment, physical violence or sexual assault at work specifically because of their gender identity. We estimated the prevalence of each type of violence stratified by gender identity, race/ethnicity, age, educational attainment, history of working in the street economy (eg, sex industry, drug sales) and if people at work knew their gender identity. RESULTS:Workplace violence was prevalent, with 50% of transgender and non-binary workers having ever experienced harassment, 7% physical violence and 6% sexual assault at work because of their gender identity. Harassment was common among all of these workers, but physical violence and sexual assault were more than twice as common among transfeminine and non-binary workers assigned male at birth, workers of colour, workers with low educational attainment and those who had ever worked in the street economy. CONCLUSIONS:Transgender and non-binary workers commonly face violence at work because of their gender identity. Workplace violence prevention programmes should incorporate ways to prevent gender identity-based violence and facilitate channels for workers to report the occurrence of discrimination and violence.

Introduction Profound sexual health disparities exist for Black men who have sex with men (MSM) in the US South, including a high prevalence of sexually transmitted infections (STIs). Sexually transmitted infection prevention strategies beyond condoms are needed for Black MSM taking preexposure prophylaxis (PrEP). Methods We conducted in-depth interviews with Black MSM taking PrEP in New Orleans, Louisiana. Informed by the Health Belief Model, we asked about participants' perceived susceptibility, severity, and concerns regarding STIs, and perceived benefits of STI prevention. We also asked about willingness to use various STI prevention strategies, including antibiotic prophylaxis. Interviews were audio-recorded and analyzed using applied thematic analysis. Results We interviewed 24 Black MSM aged 18 to 36 years; half had a recent STI diagnosis. Most participants were concerned about receiving an STI diagnosis, noting shame or disappointment; physical effects were concerning but infrequently considered. Participants described being less likely to use condoms with routine partners or those taking PrEP. Most reported being willing to engage in each of the 6 prevention strategies discussed. Conclusions Black MSM taking PrEP voiced concern about STIs, and many noted that they infrequently use condoms. They were willing to engage in methods focused on preventing STIs on an individual or population level.

Multiple aspects of Black young men who have sex with men's (YMSM) identities cause them to be differentially targeted for arrest and incarceration. However, limited research has explored structural drivers of Black YMSM' criminal justice involvement, particularly co-occurring forms of discrimination. This article examines the temporal relationship between perceived racial discrimination, perceived sexual orientation discrimination, and community-level HIV discrimination and criminal justice involvement among Black YMSM in North Carolina. The study followed 465 Black YMSM from November 2013 to October 2016 who were recruited for a randomized controlled trial to test an internet-based intervention for Black YMSM living with, and at risk for HIV; participants completed online surveys at baseline, 3, 6, and 12 months. Logistic regression was used to explore the relationship between the three predictors at baseline (i.e., perceived racism and sexual orientation discrimination and community-level HIV discrimination) and criminal justice involvement at follow-up. All three predictor variables were significantly associated with subsequent criminal justice involvement in separate regression models that adjusted for other covariates: HIV discrimination (aOR = 1.06 [1.01-1.11]), perceived sexual orientation discrimination (aOR = 1.12 [1.00-1.27]), and perceived racism (aOR = 1.26 [1.12-1.42]). Perceived racism remained significant in the model with all three predictors (aOR = 1.29 [1.07-1.55]). Racism did not modify the relationship between HIV discrimination and perceived sexual orientation discrimination and criminal justice involvement. This study expands existing research by exploring racism as a structural driver of criminal justice involvement; we subsequently examined whether racism modified the effect of the two other predictors. It also contributes to research on co-occurring discrimination by examining their impact on an underrepresented population.

BACKGROUND:Sexual and gender minorities (SGM) experience higher rates of discrimination and violence when compared to cis, heterosexual peers. However, violent crimes and other hate incidents against SGM persons are consistently not reported and prosecuted because of chronic distrust between the SGM community and police. Brazil is one of the most dangerous countries for SGM persons globally. Herein, we describe the development of a mobile health intervention to address the rampant violence against this population, the Rainbow Resistance-Dandarah app.METHODS:We conducted community-based participatory research (CBPR) between 2019 and 2020. The study started with in-depth interviews (IDIs) and focus group discussions (FGDs) with representatives of the SGM community from Brazil. Descriptive qualitative data analysis included the plotting of a 'word cloud', to visually represent word frequency, data coding and analysis of more frequent themes related to app acceptability, usability, and feasibility. A sub-sample of SGM tested the app and suggested improvements, and the final version was launched in December 2019.RESULTS:Since the app was launched in December 2019, the app recorded 4,114 active SGM users. Most participants are cisgender men (50.9%), self-identified as gay (43.5%), White (47.3%), and aged 29 or less (60.9%). FGDs and IDIs participants discussed the importance of the app in the context of widespread violence toward SGM persons. Study participants perceived this mHealth strategy as an important, effective, and accessible for SGM surviving violence. The CBPR design was highlighted as a key strategy that allowed SGM persons to collaborate in the design of this intervention actively. Some users reported how the panic button saved their lives during violent attacks.CONCLUSIONS:Rainbow Resistance-Dandarah app was endorsed as a powerful tool for enhancing reporting episodes of violence/discrimination against SGM persons and a key strategy to connect users with a safe network of supportive services. Results indicate that the app is an engaging, acceptable, and potentially effective mHealth intervention. Participants reported many advantages of using it, such as being able to report harassment and violence, connect with a safe network and receive immediate support.

Profound sexual health disparities exist for Black men who have sex with men (MSM) in the US South, including a high prevalence of sexually transmitted infections (STIs). Sexually transmitted infection prevention strategies beyond condoms are needed for Black MSM taking preexposure prophylaxis (PrEP).

Discrimination and violence are widely experienced by sexual and gender minority (SGM) persons worldwide. More than one SGM person is murdered every day in Brazil because of their sexuality or gender identity, which is the highest reported homicide rate in the world. Alt-hough discrimination and violence against SGM persons in Brazil are considered to be hate crimes, reporting is still suboptimal due to fear of police SGM phobia and victim blaming. Accessible and easily disseminated interventions are urgently needed. Herein, we describe the develop-ment of an mHealth solution to help address violence against SGM persons, namely the Rainbow Resistance: Dandarah App, with a synthesis of key results and feedback from the SGM community after 24 months of using the app. Twenty-two focus group discussions (FGDs) were conducted with SGM persons living in six Brazilian states: Bahia, Federal District, São Paulo, Rio de Janeiro, Minas Gerais, Sergipe, and Pará. A total of 300 SGM persons participated in the FGDs. A thematic analysis was performed to interpret the qualitative data. Content themes related to aesthetics, us-ability, barriers to resources, and likes/dislikes about the intervention arose from the FGDs. Participants found the intervention to be user-friendly, endorsed more likes than dislikes, and suggested a few changes to the app. The findings suggest that the intervention is usable and fit for future ef-fectiveness testing, and that it could fill an important gap in the well-being of SGM persons living in a country with high levels of discrimination and violence towards this community, i.e., Brazil.

Young Black gay and bisexual men who have sex with men experience stigma related to race, gender expression, sexuality and HIV status. Stigma impacts access to HIV care and prevention as well as interactions with healthcare providers. The amplification of stigma through popular media is under-researched in the health sciences. HealthMpowerment is a mobile phone optimised intervention to reduce sexual risk and support community-building for young Black gay and bisexual men (age 18-30). We analysed Forum conversations from 48 participants, 45.8% living with HIV. Of 322 stigma-relevant conversations, 18.9% referenced the media (e.g. television, news, social media) as a source of stigma. Forum conversations covered media representations of Black gay and bisexual men, media's influence on identity, and the creation of stigma by association with media representations. Cultural messages embedded in the media may accentuate stereotypes that influence perceptions of Black gay and bisexual men and disregard intersectional identities. HealthMpowerment provided a space to challenge stigmatising representations. Participants used HealthMpowerment to garner social support and celebrate positive media representations. Interventions for young Black gay and bisexual men should consider the influential role of media and include spaces for participants to process and address stigma.

Black gay, bisexual, and other men who have sex with men (BMSM) in the US South are disproportionately impacted by HIV. We adapted Project Strength Through Youth Livin' Empowered (STYLE) to create STYLE 2.0 to assist young BMSM link and remain engaged in HIV care. The multi-component intervention included (1) health care navigators to facilitate linkage and engagement activities, (2) motivational interviewing by a behavioral health provider, and (3) a mobile app to reduce stigma and social isolation. We enrolled 66 BMSM from North and South Carolina in the 12-month intervention and analyzed longitudinal data to assess service utilization, dose, and delivery characteristics while also examining changes in HIV care continuum outcomes. We examined associations between intervention characteristics and HIV care continuum outcomes using logistic regression. We found that all HIV outcomes improved from baseline to 12-month follow-up, including receipt of HIV care (78.8-84.9%), retention in HIV care (75.9-87.7%), being prescribed antiretroviral therapy (ART) (96.8-98.5%), and achieving viral suppression (82.3-90.8%), although none were statistically significant. In multi-variable analyses, participants with more encounters categorized as food bank were more likely to report being prescribed ART [odds ratio (OR): 41.65; 95% confidence interval (CI): 2.72-637.74]. Clients with more referral to care encounters were less likely to have been prescribed ART (OR: 0.02; 95% CI: <0.001-0.42) and be virally suppressed (OR: 0.39; 95% CI: 0.18-0.84). Findings suggest that an integrated approach to HIV and behavioral health services may help BMSM living with HIV overcome structural and social barriers to HIV care.

BACKGROUND:HIV disproportionately affects young Thai men who have sex with men (YMSM). Recent studies report a high incidence and prevalence of HIV among Thai YMSM. The Thai national guidelines have recommended pre-exposure prophylaxis (PrEP) since 2014 for key populations; free PrEP has been piloted since 2019. Smartphone-based mobile health (mHealth) interventions provide an optimal platform for innovative PrEP adherence interventions for Thai YMSM.OBJECTIVE:This study aims to adapt the P3 (Prepared, Protected, emPowered) app, developed with YMSM and transwomen in the United States to improve PrEP adherence and persistence for YMSM in Thailand. The app aims to provide daily adherence support and addresses gaps in staff available for large-scale PrEP rollout needed to see population-level effects of HIV prevention.METHODS:We conducted focus group discussions (FGDs) with YMSM and key informant interviews (KIIs) with PrEP care providers in Bangkok, Thailand, to investigate PrEP adherence facilitators and barriers, preferences for functions and features in mHealth apps among YMSM, and how to best adapt the P3 app to the Thai context. We conducted four FGDs with 4-8 participants per group and 15 KIIs.RESULTS:For FGDs, 23 YMSM participated with a mean age of 20 years (range 18-21), 96% (22/23) enrolled in full-time education, and all owned smartphones. The mean age of KII participants was 40 (range 26-60) years; most were state health service providers, with the majority being counselors (6/15, 40%) and physicians (6/15, 40%). Overall, the facilitators and barriers for PrEP adherence identified were similar to those of MSM and YMSM globally including the United States. Key themes included general recommendations for improving mHealth apps in Thailand, such as presenting reliable information in an appealing format, minimizing privacy risks, and addressing connectivity challenges. Additional themes focused on P3 Thailand adaptations and were related to cultural and stylistic preferences, engagement strategies, and recommendations for new functions. To develop the adapted app, P3 Thailand, these findings were balanced with resource limitations resulting in the prioritization of minor modifications: changes in app esthetics (color scheme, iconography, and imagery) and changes in the presentation of information in two of the app's features. FGDs identified similar PrEP adherence facilitators and barriers to those already addressed within the app.CONCLUSIONS:The core elements of the P3 app address major PrEP facilitators and barriers for Thai YMSM; however, changes to the app features, including stylistic presentation, were needed to appropriately customize the app to the Thai context. Given the similarities of facilitators and barriers for PrEP adherence globally, adapting existing PrEP mHealth solutions based on input from end users and key informants provides a promising approach. However, partnerships with local app designers and developers can improve the adaptation process and final product.TRIAL REGISTRATION:ClinicalTrials.gov NCT04413708; http://clinicaltrials.gov/ct2/show/NCT04413708.

Transgender and gender non-binary (TNB) individuals are disproportionately impacted by mental health disorders, substance use, and suicidal ideation and attempts than the general population.1–4 In addition, TNB individuals are more likely to experience stress due to trauma, stigma, discrimination, victimization, under/unemployment, housing instability, and lack of access to gender affirming behavioral healthcare, all of which contribute to poor behavioral health outcomes.1,5–8 In the southern region of the US, where the largest number and proportion of TNB individuals reside, cultural conditions that contribute to significant LGBTQ+ stigma and discrimination, racism, fewer educational and employment opportunities, and greater overall poverty further compound the risks of behavioral health disparities.9–12

Wharton, Mitchell J. PhD, RN, FNP-BC, CNS; Harris, Orlando O. PhD, RN, MPH, FNP; Chapman Lambert, Crystal PhD, CRNP, FNP-BC, ACRN; LeGrand, Sara PhD Author Information

Background Mobile health platforms can facilitate social support and address HIV (human immunodeficiency virus) stigma but pose challenges for intervention design and participant engagement. Giddens's structuration theory, that individuals are shaped by-and shape-their communities through rules and resources that give them power to operate within these environments, provides a useful analytic framework for exploring these dynamic intervention spaces. Method Data were drawn from an online randomized controlled trial intervention (HealthMpowerment) for young Black men who have sex with men to reduce condomless anal intercourse. We applied a conversational analysis informed by structuration theory to 65 user-generated conversations that included stigma content. We aimed to understand how the interdependent relationship between the intervention space and participants' contributions might contribute to behavior change. Results Thirty five intervention participants contributed to the analyzed conversations. Our analysis identified three types of conversational processes that may underlie behavior change: (1) Through intervention engagement, participants established norms and expectations that shaped their discussions; (2) participants used anecdotes and anonymity to reinforce norms; and (3) intervention staff members sought to improve engagement and build knowledge by initiating discussions and correcting misinformation, thus playing an integral role in the online community. Conclusions The lens of structuration theory usefully reveals potential behavior change mechanisms within the social interactions of an online intervention. Future design of these interventions to address HIV stigma should explicitly characterize the context in which individuals (study staff and participants) engage with one another in order to assess whether these processes are associated with improved intervention outcomes.

Introduction During the last ten years Brazil has been registering at least one murder of LGBTQI+ person every day. While violence is widespread, interventions are scarce and often discontinued. We developed a novel mobile health (mHealth) intervention to address the rampant discrimination and violence against LGBTQI+ persons from Brazil. Methods We utilized a community-based participatory research (CBPR) approach to collect quantitative and qualitative data from the Brazilian LGBTQI+ community. The data underscored the development of a mobile app, the “Rainbow Resistance- Dandarah App”. Summary The study included 11 members from the Brazilian LGBTQI+ community on the Community Advisory Board (CAB). Fourteen focus groups discussions (FGDs) were conducted with 8-10 LGBTQI+ persons each, including rural and urban cities, as well as hard to reach areas from Brazil (e.g. slums and the Amazon Area). Ten in-depth interviews (IDIs) were then conducted with key informants, the vast majority of whom were community leaders and professionals providing services for LGBTQI+ persons experiencing discrimination/violence. Descriptive analysis of qualitative FGDs data included plotting a‘word cloud’ to visually represent word frequency. The most mentioned word was “violence”, followed by “safe”, “streets” and “alive”. Since its launch, over 4,000 have utilized the Rainbow Resistance – Dandarah app. Most participants to date are men, self-identified as gay/homosexual, White, with a median age of 26 years. The panic button was activated 61 times. The “Rainbow Resistance- Dandarah App” had high acceptability, feasibility and anticipated usability. Discussion: Many FGDs participants mentioned the importance of the collaborative strategy utilized in the study, where the LGBTQI+ community was consulted to identify their specific needs, were invited to compose a highly active CAB, tested the app prototype and had the opportunity to criticize and contribute to final app improvements. Study participants requested additional features, including legislation relevant to the LGBTQI+ community and addresses of local services, non-governmental organizations, shelters, etc. Those additional features, including mental health screening and referrals to specialized care, are under development.

Sexual empowerment represents an important HIV intervention strategy, yet limited attention has examined the multidimensional nature of sexual empowerment in prior studies. Using a sample (n = 465) of young Black men who have sex with men (MSM), we used confirmatory factor analysis (CFA) to test a multifactorial operationalization of sexual empowerment. CFA indicated that a bifactor model was best suited to characterize the sexual empowerment factor (SEF), suggesting that items for four sub-constructs (self-efficacy to refuse sexual behavior, emotional support, condom use self-efficacy, and social norms on condom use) contributed to their respective constructs, while also contributing to a latent sexual empowerment construct. We then examined the association between SEF and mental health outcomes (anxiety and depression symptoms) and safer sex intentions. SEF was negatively associated with mental health outcomes and positively associated with safer sex intentions. Ultimately, individuals with greater sexual empowerment might be better equipped to develop strategies to buffer their vulnerability to HIV. We discuss the implications of SEF as a bifactor during the design and evaluation of HIV risk-reduction interventions seeking to address sexual empowerment among MSM.

BACKGROUND In Thailand, HIV disproportionately affects men who have sex with men (MSM). Recent studies indicate a high incidence and prevalence of HIV in Bangkok among MSM, with higher risk of infection for young men who have sex with men (YMSM). Pre-exposure prophylaxis (PrEP) is a safe and efficacious method for preventing transmission of HIV. The Thai national guidelines have recommended PrEP since 2014 for key poulations nationwide and the government has piloted free PrEP coverage since October 2019. Smartphone based mHealth interventions provide an optimal platform to deliver innovative PrEP adherence interventions for Thai YMSM. OBJECTIVE This study aimed to conduct formative research to adapt the P3 (Prepared, Protected, emPowered) app, developed with MSM and transwomen in the United States to improve PrEP adherence and persistence, for YMSM in the Thai context. METHODS We conducted focus group discussions (FGDs) with YMSM and key informant interviews (KIIs) with PrEP care providers in Bangkok, Thailand to better understand: a) PrEP adherence facilitators and barriers b) preferences for functions and features in mHealth apps among YMSM; and c) how to best adapt the P3 app to the Thai context. We conducted 4 FGDs with 4-8 participants per group and 15 KIIs in Bangkok, Thailland. RESULTS For FGDs, a total of 23 YMSM participated with a mean age of 20 years (range 18-21), 96% enrolled in full-time education, and all owned smartphones. The mean age of KII participants was 40 (range 26-60); most were publicly employed health service providers with the majority of them being counselors (40%) and physicians (40%). Overall, the facilitators and barriers for PrEP adherence identified were similar to those of MSM and YMSM in the US and other parts of the world. Key themes included general recommendations for improving mHealth apps in Thailand, such as presenting reliable information in an appealing format, minimizing privacy risks, and addressing connectivity challenges. Additional themes focused on P3T adaptations and were related to cultural and stylistic preferences, engagement strategies, and recommendations for new functions. To develop the adapted app, P3 Thailand (P3T), these findings were balanced with resource limitations resulting in prioritization of minor modifications in app aesthetics and changes in the presentation and content of information in two of the app’s features. CONCLUSIONS The core features of the P3 app address the main PrEP facilitators and barriers for Thai YMSM, However, substantive changes to the stylistic presentation and content were needed to appropriately tailor and customize the app for the Thai context. Based on the similarities of facilitators and barriers for PrEP adherence globally, adapting existing PrEP mHealth solutions based on input from end-users and key informants provides a promising way forward. However, partnerships with local app designers and developers could improve the adaptation process and final product. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT04413708

Around the world, transgender and gender diverse (TGD) people experience striking disparities in mental health outcomes.1Reisner SL Poteat T Keatley J et al.Global health burden and needs of transgender populations: a review.Lancet. 2016; 388: 412-436Summary Full Text Full Text PDF PubMed Scopus (601) Google Scholar TGD individuals are more likely to suffer from post-traumatic stress disorder, anxiety, depression, substance use disorders and suicidality compared to the wider population.1Reisner SL Poteat T Keatley J et al.Global health burden and needs of transgender populations: a review.Lancet. 2016; 388: 412-436Summary Full Text Full Text PDF PubMed Scopus (601) Google Scholar These disparities are thought to be secondary to a range of factors including inadequate access to gender-affirming care, minority stress, and discriminatory public policies.2Hatzenbuehler ML Pachankis JE Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical implications.Pediatr Clin North Am. 2016; 63: 985-997Summary Full Text Full Text PDF PubMed Scopus (339) Google Scholar, 3White Hughto JM Reisner SL Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions.Soc Sci Med. 2015; 147: 222-231Crossref PubMed Scopus (694) Google Scholar Structural factors increase vulnerability among TGD people to discrimination and violence, limit educational and job opportunities, increase the likelihood of poverty, undermine housing stability, restrict access to health care, and contribute to social exclusion.3White Hughto JM Reisner SL Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions.Soc Sci Med. 2015; 147: 222-231Crossref PubMed Scopus (694) Google Scholar Gender affirmation across legal, medical, surgical, psychological, and social domains appears in particular to have profound effects on the health outcomes of TGD individuals.1Reisner SL Poteat T Keatley J et al.Global health burden and needs of transgender populations: a review.Lancet. 2016; 388: 412-436Summary Full Text Full Text PDF PubMed Scopus (601) Google Scholar According to the UN, "…it is vital that States fully recognize gender diversity in order to guarantee full exercise of all the human rights of everyone, including trans and gender diverse persons".4UN Office of the High Commissioner for Human RightsStatement on the occasion of International Transgender Day of Visibility, the IACHR and a UN expert urge States to guarantee the full exercise of the human rights of transgender persons.https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=22906&LangID=EDate accessed: March 9, 2020Google Scholar The UN has persisted in their commitment to make gender congruent identity documents (IDs) for TGD people available. In 2018, a UN-appointed expert upheld a recommendation made by the UN High Commissioner for Human Rights that states should create simple administrative processes to issue legal IDs that reflect gender identity solely based on individual choice.5UN General AssemblyReport of the Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity.https://www.un.org/en/ga/search/view_doc.asp?symbol=A/73/152Date accessed: March 9, 2020Google Scholar However, TGD people in many parts of the world face substantial barriers or a complete inability to obtain gender-congruent IDs, which indicates a failure among several UN member states, including the USA, to uphold a basic human right for their TGD citizens. Not being able to access gender-congruent IDs also impacts other fundamental rights, such as the right to self-determination, dignity, and freedom, and it impairs the ability of TGD people to travel, access education, seek employment, collect social benefits, and access health care. Other potentially dire consequences associated with an incongruent ID include increased harassment, discrimination, and social isolation, which could have direct impacts on health and quality of life. Although it is clear that the inability to obtain gender-congruent IDs undermines TGD individuals' human rights, little is known about the direct association between gender-affirming IDs and mental health outcomes among TGD people. In an effort to begin to address this gap in the literature, Scheim and colleagues6Scheim AI Perez-Brumer AG Bauer GR Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study.Lancet Public Health. 2020; (published online March 16.)https://doi.org/10.1016/S2468-2667(20)30032-3Summary Full Text Full Text PDF Scopus (44) Google Scholar did a secondary data analysis in The Lancet Public Health that included 22 286 TGD participants from the 2015 US Transgender Survey—the largest survey conducted to date. According to the study, 10 288 (weighted percentage 45·1%) of the respondents did not have their preferred name and gender marker on any IDs, whereas 2332 (10·7%) had all IDs congruent with their identified name and gender marker. When compared with participants with no gender-congruent ID, those with all congruent IDs had lower prevalence of severe psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61–0·76), suicidal ideation (0·78, 0·72–0·85), and suicide planning (0·75, 0·64–0·87). Scheim and colleagues6Scheim AI Perez-Brumer AG Bauer GR Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study.Lancet Public Health. 2020; (published online March 16.)https://doi.org/10.1016/S2468-2667(20)30032-3Summary Full Text Full Text PDF Scopus (44) Google Scholar highlight a range of potential mechanisms through which gender incongruent IDs influence the mental health of TGD people. Not having gender-congruent IDs might increase their risk of experiencing discrimination and violence in non-affirming environments. The increased psychological distress associated with using an ID that does not match one's identity and the frequent experience of structural violence affects the willingness and ability to look for care.7Kattari SK Bakko M Hecht HK Kattari L Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults.SSM Popul Health. 2019; 10100525Crossref PubMed Scopus (40) Google Scholar Not having legal affirmation of one's gender identity impairs TGD people's access to health care, employment, and social services, among others. This scenario increases the likelihood of health-care avoidance by those most in need.3White Hughto JM Reisner SL Pachankis JE Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions.Soc Sci Med. 2015; 147: 222-231Crossref PubMed Scopus (694) Google Scholar The cross-sectional study design prohibits causal interpretation of the identified relationships, and reverse causation is plausible—those with better mental health might be better able to navigate the difficult bureaucratic requirements to obtain gender congruent IDs. Even with those limitations, the large dataset and careful inclusion of potential confounders strengthen the study design. Thus, the authors' findings support the need to increase the availability of and streamline the processes to obtain gender congruent IDs. Gaining gender-congruent IDs should be easy, affordable, and quickly completed by adequately trained officials at TGD-friendly environments.8Winter S Diamond M Green J et al.Transgender people: health at the margins of society.Lancet. 2016; 388: 390-400Summary Full Text Full Text PDF PubMed Scopus (464) Google Scholar The authors report that participants with gender-concordant IDs had a lower prevalence of suicidal ideation and suicide planning. However, it is important to note that even among those with all gender-concordant IDs, 712 (30·0%) of respondents reported suicidal ideation in the previous year, substantially higher than the general population in the USA. This high rate speaks to the fact that although gender-concordant IDs are one crucial aspect of improving mental health among this population, a range of other factors continue to contribute to mental health disparities. These factors include a low level of family support for TGD people's gender identity, exposure to gender identity conversion efforts, high rates of poverty, unstable housing, and inadequate access to gender-affirming care, to name a few.1Reisner SL Poteat T Keatley J et al.Global health burden and needs of transgender populations: a review.Lancet. 2016; 388: 412-436Summary Full Text Full Text PDF PubMed Scopus (601) Google Scholar, 7Kattari SK Bakko M Hecht HK Kattari L Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults.SSM Popul Health. 2019; 10100525Crossref PubMed Scopus (40) Google Scholar, 9Turban JL Beckwith N Reisner SL Keuroghlian AS Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults.JAMA Psychiatry. 2020; 77: 68-76Crossref PubMed Scopus (72) Google Scholar The study is highly relevant to efforts to improve the health and wellbeing of transgender populations. We hope that the results will encourage governments worldwide to remove barriers to gender-congruent IDs for TGD people. Although such initiatives will probably improve mental health disparities experienced by this population, more work needs to be done. We must also address the multitude of other factors contributing to these disparities, including the high rates of violence and discrimination, limited access to gender-affirming medical, surgical, and mental health care, and a litany of minority stressors experienced by TGD populations. We declare no competing interests. Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional studyPossession of gender-concordant IDs might improve mental health among trans persons. Gender recognition policies should be considered structural determinants of transgender health. Full-Text PDF Open AccessTransgender health, identity, and dignityAlthough some progress has been made, transgender people still face substantial discrimination and threats to their health and wellbeing. Despite a clear need for greater monitoring and understanding of transgender health, current research is both sparse and fragmented. Full-Text PDF Open Access

Worldwide, Brazil has the highest prevalence of violence and hate crimes against sexual and gender minorities (SGMs) among countries with available data. To explore the impact of this scenario, we conducted a qualitative study with 50 SGMs from Rio de Janeiro, Brazil. Among the participants, 66% screened positive for generalised anxiety disorder, 46% for major depressive disorder and 39% for PTSD. A third reported low self-esteem (32%) and one quarter low social support (26%). Experiences of interpersonal discrimination were highly prevalent (>60%), while institutional discrimination related to employment or healthcare was reported by 46% of participants. Verbal abuse is very common (80%), followed by physical assault (40%). Sexual violence is highly frequent among women. Focus groups analysis highlighted three major domains: (1) stigma and discrimination (family, friends and partners, in schools and health services, influencing social isolation); (2) violence (bullying, harassment, physical and sexual violence); and (3) mental suffering (alcohol and drug abuse, depression, suicidality, anxiety). Our findings suggest a close synergy between experiences of discrimination and violence with selected mental disorders. This complex synergy might be better addressed by longer-term individual and group-level interventions that could foster social solidarity among the different groups that comprise SGMs.

On January 2019, Brazil's new far-right president Jair Bolsonaro was sworn into office. Bolsonaro's administration supports downsizing the Brazilian Unified Health System (SUS), while increasing the size of the private health sector. The new administration might leave millions of Brazilians without medical care, including hundreds of thousands of people living with HIV/AIDS. Bolsonaro's administration, allied with a highly conservative Congress and sharp decreases in federal funding for public health, education and research, could jeopardize key health and human rights strategies focused on women, LGBTQ + individuals, Indigenous populations, and people living with HIV/AIDS.