Health Service Utilization and Its Associations with Depression and Sexual Risk Behaviors Among Transgender Women in Shanghai,China

Abstract

Purpose:

Given the limited research on health care utilization among transgender women in China, we described the use of primary health care and gender-affirming health care, and the associations between utilization of gender-affirming health care and depression and sexual risk behaviors.

Methods:

We conducted a cross-sectional survey in 2017 among a purposive sample of transgender women in Shanghai, China (N=199). We examined correlates of health care utilization and its association with depression and sexual risk behaviors with Chi-square (χ²), Fisher's exact tests, and analysis of variance.

Results:

The majority of the sample (78.5%) only had physician appointments when having an illness, while about one-fifth of the sample had physician appointments for yearly checkups. Nineteen out of 199 participants (9.5%) received gender-affirming surgery, among which only five used hormone therapy prescribed by a doctor (26.3%). Receiving some form of gender-affirming surgery was associated with higher depression scores [Welch's F_{(2, 12.22)}=4.16, p=0.04], engagement in sex work (p=0.001), having 7 or more male sexual partners in the last 30 days (p=0.003), lifetime unprotected sex with a man (p=0.050), and unprotected sex with a main partner (p=0.043). Compared with transgender women who received both breast augmentation and vulvo-vaginoplasty (mean=5.86), those who received breast augmentation only (mean=12.33) scored higher on depression (p=0.04).

Conclusions:

Access to gender-affirming health care is low among transgender women in this study. The utilization of gender-affirming surgery is associated with depression and sexual risk behaviors. Findings suggest China should establish national guidelines on transgender-related health care and set up more clinics to provide consultation and services for the transgender population in China.

Get full access to this article

View all access options for this article.

References

Reisner

, Poteat

, Keatley

, et al. Global health burden and needs of transgender populations: A review. Lancet, 2016; 388(10042):412–436; doi: 10.1016/S0140-6736(16)00684-X.

White Hughto

, Reisner

, Pachankis

. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med, 2015; 147:222–231; doi: 10.1016/j.socscimed.2015.11.010.

Lai

, Chiu

, Gadow

, et al. Correlates of gender dysphoria in Taiwanese university students. Arch Sex Behav, 2010; 39(6):1415–1428; doi: 10.1007/s10508-009-9570-y.

Puckett

, Cleary

, Rossman

, et al. Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Social Policy, 2018; 15(1):48–59; doi: 10.1007/s13178-017-0295-8.

UNDP & CWU. Legal gender recognition in China: A legal and policy review; 2018. Available from: https://www.cn.undp.org/content/china/en/home/library/democratic_governance/legal-gender-recognition-in-china--a-legal-and-policy-review-.html [Last accessed: September 9, 2020].

Beijing LGBT Center. 2017 Chinese Transgender Population General Survey Report; 2017. Available from: https://chinadevelopmentbrief.cn/publications/2017-chinese-transgender-population-general-survey-report/ [Last accessed: September 9, 2020].

Zhu

, Gao

, Gillespie

, et al. Health care and mental wellbeing in the transgender and gender-diverse Chinese population. Lancet Diabetes Endocrinol, 2019; 7(5):339–341; doi: 10.1016/S2213-8587(19)30079-8.

Ainsworth

, Spiegel

. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res, 2010; 19(7):1019–1024; doi: 10.1007/s11136-010-9668-7.

Glynn

, Gamarel

, Kahler

, et al. The role of gender affirmation in psychological well-being among transgender women. Psychol Sex Orientat Gend Divers, 2016; 3(3):336–344; doi: 10.1037/sgd0000171.

10.

Yang

, Wang

, Hao

, et al. Sex partnership and self-efficacy influence depression in Chinese transgender women: A cross-sectional study. PLoS One, 2015; 10(9):e0136975; doi: 10.1371/journal.pone.0136975.

11.

Infante

, Sosa-Rubi

, Cuadra

. Sex work in Mexico: Vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex, 2009; 11(2):125–137; doi: 10.1080/13691050802431314.

12.

Logie

, Wang

, Lacombe-Duncan

, et al. Factors associated with sex work involvement among transgender women in Jamaica: A cross-sectional study. J Int AIDS Soc, 2017; 20(1):21422; doi: 10.7448/ias.20.1.21422.

13.

Sevelius

. Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 2013; 68(11–12):675–689; doi: 10.1007/s11199-012-0216-5.

14.

Nemoto

, Cruz

, Iwamoto

, et al. Examining the sociocultural context of HIV-related risk behaviors among Kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care, 2016; 27(2):153–165; doi: 10.1016/j.jana.2015.11.003.

15.

Shen

, Csete

. HIV, Sex work, and law enforcement in China. Health Hum Rights, 2017; 19(2):133–146; PMID: 29302171; PMCID: PMC5739365.

16.

Yan

, Xiao

, Chen

, et al. High HIV prevalence and associated risk factors among transgender women in China: A cross-sectional survey. J Int AIDS Soc, 2019; 22(11):e25417; doi: 10.1002/jia2.25417.

17.

Cai

, Wang

, Lau

JTF

, et al. Prevalence and associated factors of condomless receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China. J Int AIDS Soc, 2016; 19(3 Suppl 2):20800; doi: 10.7448/ias.19.3.20800.

18.

Suen

, Chan

RCH

. Prevalence and risk and protective factors associated with HIV-related behavior among transgender people in Hong Kong. J Gay Lesbian Soc Serv, 2020; 32(2):148–163; doi: 10.1080/10538720.2019.1690609.

19.

Sevelius

, Reznick

, Hart

, et al. Informing interventions: The importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Educ Prev, 2009; 21(2):113–127; doi: 10.1521/aeap.2009.21.2.113.

20.

Nemoto

, Operario

, Keatley

, et al. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care, 2004; 16(6):724–735; doi: 10.1080/09540120413331269567.

21.

Sausa

, Keatley

, Operario

. Perceived risks and benefits of sex work among transgender women of color in San Francisco. Arch Sex Behav, 2007; 36(6):768–777; doi: 10.1007/s10508-007-9210-3.

22.

Chng

, Wong

, Park

, et al. A model for understanding sexual health among Asian American/Pacific Islander men who have sex with men (MSM) in the United States. AIDS Educ Prev, 2003; 15(1 Suppl A):21–38; doi: 10.1521/aeap.15.1.5.21.23611.

23.

Poulin

, Hand

, Boudreau

. Validity of a 12-item version of the CES-D [Centre for Epidemiological Studies Depression scale] used in the national longitudinal study of children and youth. Chronic Dis Can, 2005; 26(2–3):65–72; PMID: 16251012.

24.

Yan

, Wong

, Zheng

, et al. Social support and depressive symptoms among “money” boys and general men who have sex with men in Shanghai, China. Sex Health, 2014; 11(3):285–287; doi: 10.1071/sh14017.

25.

Wang

, Barile

, Simoni

, et al. Intimate partner violence among Chinese transwomen: Associations with sexual risk behaviors and HIV testing. Sex Transm Dis, 2021; 48(5):362–369; doi: 10.1097/OLQ.0000000000001317.

26.

Analysis of Healthcare Insurance Coverage in China, 2019. Cinda Securities Company Limited; 2019. Available from: https://pdf.dfcfw.com/pdf/H3_AP202011261433406799_1.pdf?1606420017000.pdf [Last accessed: October 26, 2021].

27.

Lerner

, Robles

. Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. J Health Care Poor Underserved, 2017; 28(1):127–152; doi: 10.1353/hpu.2017.0014.

28.

Safer

, Coleman

, Feldman

, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes, 2016; 23(2):168–171; doi: 10.1097/MED.0000000000000227.

29.

Yan

, Lin

, Xiao

W-J

, et al. Identity, stigma, and HIV risk among transgender women: A qualitative study in Jiangsu Province, China. Infect Dis Poverty, 2019; 8(1):94; doi: 10.1186/s40249-019-0606-9.

30.

De Santis

, Cintulova

, Provencio-Vasquez

, et al. Transgender women's satisfaction with healthcare services: A mixed-methods pilot study. Perspect Psychiatr Care, 2020; 56(4):926–938; doi: 10.1111/ppc.12514.

31.

Rodriguez

, Agardh

, Asamoah

. Self-reported discrimination in health-care settings based on recognizability as transgender: A cross-sectional study among transgender U.S. citizens. Arch Sex Behav, 2018; 47(4):973–985; doi: 10.1007/s10508-017-1028-z.

32.

Bradford

, Reisner

, Honnold

, et al. Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health, 2013; 103(10):1820–1829; doi: 10.2105/AJPH.2012.300796.

33.

Kcomt

. Profound health-care discrimination experienced by transgender people: Rapid systematic review. Soc Work Health Care, 2019; 58(2):201–219; doi: 10.1080/00981389.2018.1532941.

34.

Porter

, Brennan-Ing

, Chang

, et al. Providing competent and affirming services for transgender and gender nonconforming older adults. Clin Gerontol, 2016; 39(5):366–388; doi: 10.1080/07317115.2016.1203383.

35.

Safer

. Hurdles to health care access for transgender individuals. Nat Hum Behav, 2019; 3(11):1132–1133; doi: 10.1038/s41562-019-0693-4.

36.

Selvaggi

, Bellringer

. Gender reassignment surgery: An overview. Nat Rev Urol, 2011; 8(5):274–282; doi: 10.1038/nrurol.2011.46.

37.

Centers for Disease Control and Prevention. Screening in Clinical Settings; 2019. Available from: https://www.cdc.gov/hiv/clinicians/screening/clinical-settings.html [Last accessed: September 9, 2020].

38.

Guadamuz

, Wimonsate

, Varangrat

, et al. HIV prevalence, risk behavior, hormone use and surgical history among transgender persons in Thailand. AIDS Behav, 2011; 15(3):650–658; doi: 10.1007/s10461-010-9850-5.

39.

2017 Chinese transgender population general survey report. China development brief; 2017. Available from: https://www.chinadevelopmentbrief.cn/publications/2017-chinese-transgender-population-general-survey-report/ [Last accessed: May 25, 2020].

40.

White Hughto

, Reisner

. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health, 2016; 1(1):21–31; doi: 10.1089/trgh.2015.0008.

41.

Tucker

, Testa

, Simpson

, et al. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans. Psychol Med, 2018; 48(14):2329–2336; doi: 10.1017/S0033291717003853.

42.

Mahfouda

, Moore

, Siafarikas

, et al. Gender-affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol, 2019; 7(6):484–498; doi: 10.1016/S2213-8587(18)30305-X.

43.

Coleman

, Bockting

, Botzer

, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend, 2012; 13(4):165–232; doi: 10.1080/15532739.2011.700873.