Physical and/or Sexual Abuse Are Associated with Negative Health Outcomes Among Transgender Women of Color Living with HIV

Abstract

Transgender women experience elevated rates of physical and sexual abuse relative to cisgender women and cisgender men, with transgender women of color demonstrating particularly elevated rates of abuse and assault. Little is known about the separate and combined effects of physical and sexual abuse on transgender women of color living with HIV. From February 2014 through August 2016, 139 trans women of color living with HIV were enrolled in a project to increase HIV care outcomes and, of those, 110 participants responded to the questions regarding physical gender abuse (PGA, i.e., physical abuse motivated by a person's gender expression) and childhood sexual abuse (CSA). Eighty percent of the participants reported a past experience of abuse including PGA (21.8%), CSA (27.3%), or both (30.9%). Multivariable regression analyses demonstrated that PGA and CSA were associated with greater likelihood of homelessness (PGA: adjusted odds ratio [AOR] = 4.2, 95% confidence interval [95% CI] [1.1, 16.5]; CSA: AOR = 6.47, 95% CI [1.6, 26.0]) and engagement in sex work (PGA: AOR = 4.3, 95% CI [1.1, 16.3]; CSA: AOR = 4.5, 95% CI [1.2, 16.5]) in the previous 6 months. Significant interaction effects revealed no additive effects of PGA and CSA, indicating similar risk of homelessness and sex work after the experience of any form of abuse. By contrast, CSA, but not PGA, was linked to increased drug use (AOR = 9.9, 95% CI [2.1, 46.9]) and use of a larger number of substances (incident rate ratio = 3.9, 95% CI [2.0, 7.9]) in the previous 6 months. Service providers working with this or similar populations should assess for past experience of physical and sexual abuse as trauma-informed services may be indicated.

Introduction

Trans women in the United States experience several negative health outcomes at higher rates than their cisgender counterparts, including HIV infection (Baral et al. 2013), homelessness (Durso and Gates 2012; Spicer et al. 2010), engagement in sex work (Baral et al. 2013; Operario et al. 2008), and drug use (Herbst et al. 2008; Reback and Fletcher 2014). These mutually reinforcing individual and structural barriers to good health constitute a “syndemic” of risk factors facing trans women, a circumstance that places trans women at higher risk for exposure to HIV, STIs, serious mental health disorders, and other negative health outcomes (Brennan et al. 2012; Hotton et al. 2013; Operario and Nemoto 2010). Trans women of color are particularly vulnerable to such syndemic risks (Baral et al. 2013; Bradford et al. 2013) as they inhabit the intersection of multiple disadvantaged and stigmatized minority statuses simultaneously.

Determining causality in the context of a syndemic is difficult given the ongoing, cyclical, and reinforcing nature of syndemic processes; individual factors (e.g., engagement in sex work and/or drug use) can serve as both a cause and a consequence of structural factors (e.g., homelessness), as various processes interconnect over time. Inference of causality is less problematic during examination of distal factors that occur earlier in time and are presumed to influence proximal factors, which, in turn, influence current health status (Reisner et al. 2015). Examples include prior physical and childhood sexual abuse (CSA) as determinants of trans women's health (e.g., Nuttbrock et al. 2013).

Rates of physical and sexual violence against trans women are consistently higher than those observed among other U.S. populations including gay/bisexual men and lesbian women (Cook-Daniels and Munson 2010; Kenagy 2005; Rothman et al. 2011). Systematic review suggests a population rate of physical assault near 43% (95% confidence interval [95% CI] [39, 47]) and a population rate of forced sex (as opposed to sexual abuse defined more broadly) of ∼21% (95% CI [17, 24]; Herbst et al. 2008). Trans women of color are particularly vulnerable to abuse and assault (Nuttbrock et al. 2010; Reisner et al. 2014), especially as youth (Grant et al. 2011).

Physical abuse has been associated with increased risk of HIV infection (Brennan et al. 2012), depression (Nemoto et al. 2011), engagement in sexual risk behavior (Brennan et al. 2012), and substance use (Reisner et al. 2015) among trans women. Physical gender abuse (PGA), defined as physical abuse that is perceived by a trans woman to be the direct result of her gender identity expression, has been shown to increase risk of exposure to HIV, mental health disorder, and engagement in HIV/STI sexual risk behaviors (Nuttbrock et al. 2013). Similarly, sexual abuse has been linked to increased risk of HIV infection (Grant et al. 2011), sexual risk behavior (Garofalo et al. 2006), substance use (Testa et al. 2012), and depression (Rotondi et al. 2012; Testa et al. 2012). Studies of trans women that assessed abuse without distinguishing between physical and sexual forms of abuse also consistently demonstrated the deleterious effects of abuse on trans women's mental health status (Kussin-Shoptaw et al. 2017; Nuttbrock et al. 2010, 2013).

To our knowledge, no study has specified both the unique and combined effects of physical and sexual abuse on individual- (e.g., sex work and drug use) and structural- (e.g., homelessness) level health disparities of trans women. This secondary data analysis is from a project with trans women of color living with HIV who, at baseline, had suboptimal HIV care and/or were not adherent to ART. The main objective of our analysis was to estimate the associations between prior experience of PGA and/or CSA and current syndemic health risks. It was hypothesized that experience of PGA and/or CSA would be associated with increased likelihood of homelessness, sex work, and drug use.

Materials and Methods

Participants

From February 2014 through August 2016, 139 participants were enrolled. Inclusion criteria were (1) identified as a trans woman, (2) assigned “male” sex on original birth certificate, (3) between the ages of 18–65 years, (4) racial/ethnic identity reported as not Caucasian/white, and (5) HIV positive and currently not in HIV care or had not seen a HIV medical provider in the previous 6 months or not prescribed ART medication or prescribed ART medication but not always adherent. Individuals were excluded if they did not meet all eligibility criteria. Results reported here were from a subgroup of 110 participants who provided data on lifetime PGA and sexual abuse that occurred before the age of 18 years.

Procedures

Participants were recruited through (1) social network recruitment and engagement methodology (i.e., respondent-driven sampling), (2) venue- and street-based outreach, (3) project flyers, (4) in-reach at other programs from the project site, (5) in-services conducted at local agencies, and (6) collaborating HIV medical care clinics. Potential participants who were unable to provide documentation of their HIV-positive serostatus (e.g., medication prescription and laboratory results) were tested onsite for verification of a positive HIV status. After consent, participants completed a baseline computer-assisted self interview assessment administered through REDCap. Participants received a $10 gift card for eligibility screening and a $25 gift card at the completion of the baseline assessment. The project was conducted at Friends Community Center, the Hollywood, CA community research site of Friends Research Institute. The project was approved by the Institutional Review Board of Friends Research Institute, Inc.

Measures

Sociodemographics

Participants were asked for their year and month of birth, whether they were of Hispanic/Latina origin, whether they identified as white, black/African American, American Indian/Alaska Native, Asian/Pacific Islander/Asian Indian, or other, and their level of educational attainment.

Childhood sexual abuse

CSA was assessed using the child sexual abuse subscale from the Early Trauma Inventory-Self Report (ETI-SR; Bremner et al. 2007), shortened list (six items).

Lifetime physical gender abuse

Participants were asked “How many times have you been punched, kicked, or beaten because you are, or were thought to be, transgender?” and were provided with a 4-point Likert scale ranging from “Never” to “Three or More Times” (Brennan et al. 2012).

Drug use

The drug use assessment was extracted from The Los Angeles Transgender Health Survey (Reback et al. 2001). Participants were asked whether they had used marijuana, methamphetamine, amphetamines, barbiturates, ecstasy, tranquilizers, hallucinogens, inhalants, powder cocaine, crack cocaine, heroin, special K, and/or primos (marijuana and rock cocaine) in the past 6 months. Each substance was assessed with a separate item.

Housing status

Participants were asked, “In the past 6 months, how often have you been homeless or temporarily or unstably housed? This can include staying with others, even for one night if you had no other place to stay” and responded to a 4-point Likert scale ranging from “Never” to “Often.”

Sex work

Participants were asked, “In the past 6 months, have you exchanged sex for money, drugs, food, clothes, a place to stay, or other things that you need?” and responded “Yes” and “No.”

Statistical analysis

Descriptive statistics for participant sociodemographics, homelessness, sex work, and drug use are provided separately for the following four abuse categories: no reported abuse, PGA only, CSA only, and both PGA and CSA. PGA and CSA were dichotomized to achieve this array of abuse status. For PGA, participants received a “0” if they responded with “Never” and a “1” for any response indicating any frequency greater than never. For CSA, participants were given a “1” if they answered “Yes” to any of the CSA items included on the ETI-SR, “0” otherwise. The dichotomous outcome variable “homelessness” was derived from the housing status item by coding a “Never” response as “0” and a response indicating a greater frequency as “1.” “Drug use” was coded as “0” if a participant reported that they had not used any drugs, and as “1” if they acknowledge the use of at least one drug. Number of drugs used was calculated as the sum of drug categories reported used in the previous 6 months.

Analysis of variance was used to test differences between means, chi-square tests were used to evaluate associations between categorical variables, and the Kruskal–Wallis test was used to assess differences in medians. The sociodemographic variables age, ethnic identity (Hispanic/Latina vs. non-Hispanic), and education (less than high school vs. high school or higher) were included as covariates in separate multivariable logistic regression analyses that regressed homelessness, sex work, and drug use on CSA and PGA, and in a multivariable negative binomial regression analysis that regressed the number of drugs used on CSA and physical abuse. Owing to missing data on the covariates and outcome variables, sample sizes for the regression analyses varied between n = 96 and n = 99. The significance level for all statistical tests was set to α = 0.05. All analyses were carried out using the R language and environment for statistical computing, version 3.3.3.

Results

As demonstrated in Table 1, a large majority of participants reported a history of abuse (n = 88, 80.0%). Abuse occurred either in the form of PGA (n = 24, 21.8%) or CSA (n = 30, 27.3%); a substantial proportion of participants experienced both types of abuse (n = 24, 30.9%).

Table 1.

Baseline Sociodemographic Characteristics and Individual- and Structural-Level Health Disparities by Abuse Status (N = 110)

	Abuse status
Characteristic	No abuse reported n = 22 M (SD), n (%), or Med (range, IQR)	Physical gender (lifetime) n = 24 M (SD), n (%), or Med (range, IQR)	Childhood sexual n = 30 M (SD), n (%), or Med (range, IQR)	Physical gender and childhood sexual n = 34 M (SD), n (%), or Med (range, IQR)	Significance
Age (years)	38.2 (9.5)	36.9 (9.7)	36.3 (10.5)	36.4 (9.2)	F_{(3, 106)} = 0.2
Ethnic identity
Non-Hispanic	12 (54.5%)	16 (72.7%)^a	20 (69.0%)^b	18 (54.5%)^c	χ²₍₃₎ = 3.0
Hispanic/Latina	10 (45.5%)	6 (27.3%)^a	9 (31.0%)^b	15 (45.5%)^c	χ²₍₃₎ = 3.0
Education
<High school	8 (36.4%)	13 (54.2%)	12 (40.0%)	12 (36.4%)^c	χ²₍₃₎ = 2.2
≥High school	14 (63.6%)	11 (45.8%)	18 (60.0%)	21 (63.6%)^c	χ²₍₃₎ = 2.2
Homelessness
No	15 (68.2%)	8 (33.3%)	8 (29.6%)^d	13 (39.4%)^c	χ²₍₃₎ = 8.7^*
Yes	7 (31.8%)	16 (66.7%)	19 (70.4%)^d	20 (60.6%)^c	χ²₍₃₎ = 8.7^*
Sex work
No	16 (76.2%)^e	10 (43.5%)^f	12 (44.4%)^d	17 (53.1%)^g	χ²₍₃₎ = 6.2
Yes	5 (23.8%)^e	13 (56.5%)^f	15 (55.6%)^d	15 (46.9%)^g	χ²₍₃₎ = 6.2
Drug use
No	12 (54.6%)	8 (34.8%)^f	4 (13.3%)	6 (18.8%)^g	two-tailed FET^**
Yes	10 (45.5%)	15 (65.2%)^f	26 (86.7%)	26 (81.3%)^g	two-tailed FET^**
Number of drugs	0.0 (0–10; 0–1)	1.0 (0–14; 0–3.5)^f	2.5 (0–13; 1–6)	2.0 (0–14; 1–4)^g	K-W χ²₍₃₎ = 15.6^**

Reported homelessness, sex work, and drug use during the past 6 months before baseline assessment.

n = 22, ^bn = 29, ^cn = 33, ^dn = 27, ^en = 21, ^fn = 23, ^gn = 32.

p ≤ 0.05, ^**p ≤ 0.01.

FET = Fisher's exact test; IQR, interquartile range; K-W = Kruskal–Wallis; M, mean; Med, median; SD, standard deviation.

Participants differing in abuse status could not be statistically differentiated in terms of age, ethnic identity, or educational attainment. Participants ranged in age from 21 to 59 years (mean = 36.8; standard deviation = 9.6), self-identified as non-Hispanic/non-Latina (60.0%) or Hispanic/Latina (36.4%), and most (58.7%) had attained at least a high school diploma (or equivalent). Chi-square analyses indicated that participants who experienced any form of abuse (i.e., only sexual abuse, only physical abuse, or both) were more likely than participants who reported no abuse to report recent (i.e., in past 6 months) homelessness (65.5% vs. 31.8%; χ²(1) = 8.1, p = 0.004), sex work (52.4% vs. 23.8%; χ²(1) = 5.5, p = 0.019), and substance use (78.8% vs. 45.5%; χ²(1) = 9.6, p = 0.002). Moreover, they also used a greater number of drugs (median [Med] = 0 vs. Med = 2; Wilcoxon rank-sum test, W = 500, p = 0.001).

Table 2 provides the results of three discrete multivariable logistic regression analyses and one negative binomial regression analysis regressing homelessness, sex work, and drug use on prior PGA and CSA status while controlling for participant age, ethnic identity, and educational attainment. Of note, although Table 2 displays adjusted log odds and their respective 95% CIs, these coefficients were written in exponentiated form as adjusted odds ratios (AORs) to facilitate their interpretation. Model I (homelessness) yielded significant effects of PGA (AOR = 4.24, 95% CI [1.09, 16.52] and of CSA (AOR = 6.47, 95% CI [1.61, 25.99], and a significant interaction (AOR = 0.12, 95% CI [0.02, 0.75]. This means that in the absence of CSA, physical abuse rendered participants four times more likely to have experienced recent homelessness (AOR = 4.24).

Table 2.

Adjusted Multivariate Logistic Regressions (Models I–III) and Negative Binomial Regression (Model IV) of Individual- and Structural-Level Health Disparities (Not Mutually Exclusive) During the Past 6 Months on Lifetime Physical Gender Abuse and Childhood Sexual Abuse

	Model I	Model II	Model III	Model IV
Model parameters	Homelessness n = 99 Coef. [95% CI]	Sex work n = 96 Coef. [95% CI]	Drug use n = 99 Coef. [95% CI]	Number of drugs n = 99 Coef. [95% CI]
PGA (lifetime)	1.44 [0.08, 2.80]^*	1.45 [0.12, 2.79]^*	0.70 [−0.62, 2.02]	0.58 [−0.17, 1.35]
CSA	1.87 [0.48, 3.26]^**	1.50 [0.19, 2.80]^*	2.29 [0.74, 3.85]^**	1.36 [0.68, 2.06]^***
PGA × CSA	−2.14 [−4.00, −0.29]^*	−2.09 [−3.82, −0.37]^*	−1.24 [−3.31, 0.83]	−0.74 [−1.68, 0.19]
Intercept	−0.71 [−1.68, 0.25]	−1.93 [−3.67, −0.18]^*	−0.16 [−1.07, 0.74]	0.01 [−0.57, 0.58]

Statistical controls: age, ethnic identity, education.

p ≤ 0.05, ^**p ≤ 0.01, ^***p ≤ 0.001.

95% CI, 95% confidence interval; Coef, coefficients; CSA, childhood sexual abuse; PGA, physical gender abuse.

Conversely, in the absence of PGA, CSA increased the likelihood of homelessness 6.5 times. The combined effect of PGA and CSA on homelessness (AOR = 3.22) was of similar magnitude as the individual effects of PGA and CSA. This was confirmed in a follow-up logistic regression analysis contrasting participants who experienced both types of abuse with participants who reported only physical abuse and participants who reported only child sexual abuse, which showed no significant group differences in the likelihood of homelessness. These findings are illustrated in Figure 1 (top left), which shows the predicted probabilities of homelessness for participants who reported no abuse, either PGA or sexual abuse, and both types of abuse.

FIG. 1.

Predicted probabilities of homelessness, engagement in sex work, and drug use, and predicted number of drugs used in the past 6 months, with covariates (age, ethnic identity, and educational attainment) fixed at their mean levels, stratified by type of abuse. Findings demonstrate no additive deleterious effect from combined physical gender abuse and childhood sexual abuse on proximal syndemic negative health outcomes. Bars depict ±1 standard error.

Results of Model II (sex work) revealed significant effects of PGA (AOR = 4.28, 95% CI [1.12, 16.29]), CSA (AOR = 4.46, 95% CI [1.21, 16.45]), and a significant interaction (AOR = 0.15, 95% CI [0.03, 0.83]). Thus, if participants experienced prior PGA but not CSA, they were about four times more likely to engage in sex work (AOR = 4.28). Similarly, in the absence of PGA, CSA also led to a fourfold increase in the likelihood of sex work (AOR = 4.46). Again, the combined effect of PGA and CSA (AOR = 2.78) was similar in magnitude as the effects of each type of abuse in isolation.

A follow-up logistic regression analysis showed no significant differences in the likelihood of sex work between participants who were exposed to both types of abuse and participants who had experienced either form of abuse (see Fig. 1, top right, for predicted probabilities of engagement in sex work). Results of Models III and IV identified CSA as a significant predictor of both drug use (AOR = 9.91, 95% CI [2.10, 46.86]) and number of drugs used (incident rate ratio [IRR] = 3.91, 95% CI [1.97, 7.87]). Thus, trans women who reported CSA were 10 times more likely to report recent drug use (AOR = 9.91; cf. Fig. 1, bottom left) and they also used a significantly larger number of drugs (IRR = 3.91; Fig. 1, bottom right, for model-predicted number of drugs used).

Discussion

In this sample of trans women of color living with HIV, only 20.0% of participants had never experienced prior PGA or CSA, demonstrating the staggering prevalence of abuse and assault experienced by this population. Though participants of differing abuse types were not distinguishable across demographic characteristics, trans women who had experienced abuse were at greater risk for recent homelessness, engagement in sex work, and drug use. Specifically, both PGA and CSA were linked to homelessness and sex work. Most revealing was that tests of statistical interaction revealed no additive effects of experiencing both types of abuse, indicating that exposure to any form of abuse, alone or in combination, had comparable detrimental outcomes regarding homelessness and engagement in sex work. However, only CSA, but not PGA, significantly increased the risk of drug use.

In a national survey of service providers working with lesbian, gay, bisexual, and transgender (LGBT) homeless youth, most homeless LGBT youth cited abuse from family members as a primary factor contributing to their homelessness, and another 12% cited their own drug use as a contributing factor (Durso and Gates 2012), further demonstrating not only links between distal abuse and proximal risk factors (e.g., homelessness) but also the syndemic links between proximal health risks (i.e., drug use and homelessness). Trans women of color living with HIV may rely on drug use to help them cope with the stress and trauma of prior abuse (Reisner et al. 2015), and/or may resort to drug use in response to housing instability (Fletcher et al. 2014). A similar association was uncovered between unstable housing and sex work among trans women (Fletcher et al. 2014), again highlighting the overlapping nature of these syndemic risks.

This project was limited by the reliance upon self-reported recall of abuse status, the lack of a sampling frame, and the reliance upon individuals who self-enrolled in an intervention to improve HIV care outcomes. The sample comprised heavily impacted trans women of color in an urban center of the United States who were HIV positive but did not receive or adhere to HIV care and/or treatment. As such, these results may not be generalizable to samples not meeting this description or the eligibility criteria. Another limitation was an inability to distinguish between different perpetuators of abuse. This may conceal important variation in the data, such as a high prevalence of intimate partner violence, familial abuse, and abuse from authority figures (e.g., law enforcement and healthcare providers; Stotzer 2009).

These data also did not include physical abuse not perceived to be related to the participants' gender identity expression, or nonphysical/nonsexual forms of abuse, including verbal harassment and psychological abuse. In addition, by focusing on CSA (as opposed to lifetime sexual abuse) and on health outcomes during the previous 6 months, it is likely that the estimates of the detrimental effects of abuse are conservative. Another limitation was the general presumption that reported instances of PGA occurred before the proximal syndemic factors examined. Although it was assumed that the majority of experiences of physical abuse predate recent episodes of homelessness, sex work, and/or drug use, this assumption may not hold. Previous studies have shown that trans women who experience financial discrimination, a potential cause/consequence of all three proximal outcomes, are estimated to be five times more likely to experience violence than those trans women who do not (Lombardi et al. 2001). Trans women who engage in sex work are at significantly higher risk for physical violence than trans women not engaged in sex work (Stotzer 2009). Such examples demonstrate how the experience of violence can serve as a proximal syndemic factor, making causal assertions about lifetime physical abuse problematic. As such, results reported here should be understood as merely associational, and not causal. Finally, episodes of short- or long-term incarceration, which are often related to homelessness, sex work, and drug use among trans women, were not examined. Trans women commonly experience abuse while incarcerated, and trans women of color are particularly vulnerable to such abuse (Grant et al. 2011).

Conclusions

National surveys indicate that trans women have significant barriers to accessing healthcare due to experiences of discrimination and abuse, and that trans women of color are at particularly high risk for abuse and discriminatory refusal of care, often resulting in suboptimal health outcomes (Grant et al. 2010). Elevated rates of discrimination, prejudice, verbal assault, and physical assault among trans women may dissuade these individuals from seeking out or accessing care. When coupled with elevated risk of HIV of trans women of color (Baral et al. 2013; Nuttbrock et al. 2009), such structural discrimination and abuse serves as a primary obstacle to the longevity and good HIV care among trans women of color.

Given the elevated rates of abuse, homelessness, engagement in sex work, drug use, and HIV among trans women in general and trans women of color in particular, interventionists working with this or similarly impacted populations may look to include trauma-informed services (Sales et al. 2016) in their programming. Trauma-informed programs provide standard-of-care services to their participants in a manner that accounts for the high rates of trauma inherent to populations accessing such services. Although there is currently a lack of evidence on the effectiveness of trauma-informed services among trans women (Hopper et al. 2010), the high rates of abuse experienced among this population situate them as prime recipients of trauma-informed services (Brezing et al. 2015; Butler et al. 2011). Future research may look to test the feasibility, acceptability, and efficacy of applying trauma-informed services among trans women of color living with HIV.

Footnotes

Acknowledgments

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H97HA24968 in the last annual award amount of $285,757 awarded to Friends Research Institute (PI: C.J.R.). No percentage of this project was financed with nongovernmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Dr. Reback acknowledges additional support from the National Institute of Mental Health (P30 MH58107). The authors would like to thank Kimberly Kisler, PhD, for her work as project director during the implementation of the project.

Author Disclosure Statement

No competing financial interests exist.

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