Physical assault partially mediates the impact of transgender status on depression and poly- substance use among Black transgender women in the United States Presented by Leigh A. Bukowski, M.P.H University of Pittsburgh, Graduate School of Public Health, Center for LGBT Health Research

Acknowledgements Co-authors: Robert W.S. Coulter, Noah C. Riley, Sean P. Buehler, Christopher Hoffmann, Alia A. Gehr-Seloover, and Ronald Stall POWER participants Community partner organizations Center for LGBT Health Research,

Significance Black men who have sex with men (MSM) and Black transgender women (BTW) are vulnerable to physical assault 60% of Black MSM report having experienced one discrimination related trauma Black transgender women are 3x more likely than their white counterparts to experience physical assault

Significance Physical assault victimization has a host of negative health implications Among Black MSM, homophobia and racism are associated with substance use and psychosocial distress Among Black transgender women, physical assault predicts depressive symptoms and illicit substance use

Significance Syndemic Theory and HIV Risk Marginalization and Stigma Development of Psychosocial Health Problems Snowballing of Psychosocial Health Problems HIV Risk HIV Infection

Significance Syndemic Theory and HIV Risk Black MSM: Average HIV incidence of 4.16% Black transgender women: Estimated HIV prevalence of 56%

Significance These populations are different Black MSM: minority status stems from race and sexual orientation Black transgender women: minority status stems from race and gender identity Because of this difference, physical assault, depression, and substance use may manifest differently in these populations

Significance Minority Stress Theory Based on Minority stress theory, transgender women may be more vulnerable t physical assault than Black MSM. Though changing, transgender identity is less socially acceptable in the United States.

Significance Little is known regarding how these health outcomes manifest differently within these populations because Black MSM and Black transgender women are often conflated for the purposes of HIV research.

Physical assault, Poly-substance Use & Depression Aim 1 Examine differences in physical assault, poly-substance use, and depression between Black transgender women and Black MSM. b a Physical assault, Poly-substance Use & Depression Transgender Status c

Poly-substance Use & Depression Aim 2 Test if physical assault mediates the effect of transgender status on poly-substance use and depression. Physical Assault a b Transgender Status Poly-substance Use & Depression c’

Methods Data comes from Promoting Our Worth, Equality, and Resilience (POWER), collaboration between the Center for Black Equity and the University of Pittsburgh, Graduate School of Public Health.

Methods In 2014 and 2015, POWER collected data during 48 Black Pride events in 6 U.S. cities using time location sampling

Behavioral Health Survey Self administered using QDS software on Dell Venue Pro tablets ~20 minutes to complete Participants compensated $10

Confidential HIV Testing Performed by local Community Based Organizations (CBOs) No changes were made to CBOs usual HIV testing procedures Participants received their test result and $10

Anonymous HIV testing Performed by POWER using OraQuick mouth swab Participants did not receive their test result, but did receive $10

Study Population POWER eligibility criteria: Study inclusion criteria: Assigned male sex at birth Currently identify as male, female, transgender Reported having a male sexual partner in their lifetime 18 years or older Study inclusion criteria: Identified as Black or African-American

Measures Transgender status: (1) assigned male sex at birth; and (2) currently identify as female or transgender; OR (2) identify as transgender or identify as having had transitioned from male to female Physical Assault: having been hit, kicked, beat-up, or in any other way physically harmed in the past-year by someone other than a partner Depression: CES-D 10, past week symptomology Poly-substance use: use of two or more illicit substances excluding marijuana in the past-year. We used a combination of both the single item and two item measures of transgender status suggested by the Williams Institute.

Analysis Aim 1: Bivariate analysis compared BTW to BMSM on poly-substance use, depression, physical assault and covariates (age, education, and city) Weighted multivariable logistic regression models, regressing poly- substance use, depression, and physical assault adjusting for age, education, and city Aim 2: Weighted multivariable logistic regression models, adjusting for covariates and physical assault Preacher and Hayes indirect macro with bootstrapping to test the significance of the indirect effect    

Results Study Population 3,426 Identified as “Black” or “African American”     3,134 Assigned MSM 290 Assigned transgender status Versus

Results: Aim 1 Comparison of Prevalence of Physical Assault, Poly-substance use, and depression among BMSM and BTW p<0.001 41% p<0.001 42% p<0.001 28% 24% 12% 8%

Results: Aim 1 When controlling for age, education, and city, compared to Black MSM, Black transgender women had: 7.2 times the odds of past-year poly substance use 3.3 times the odds of depression 5.2 times the odds of having been physically assaulted in the past year

Results: Aim 2 Poly-substance Use Physical Assault b Aim 2 a Transgender Status Poly-substance Use AOR=3.9 (95% CI: 2.6, 5.9) c’ Poly-substance Use AOR=7.2 (95% CI: 4.9, 10.6) Transgender Status Aim 1 c

Results: Aim 2 Depression Physical Assault b Aim 2 a Transgender Status Depression AOR=2.4 (95% CI: 2.5, 4.4) c’ Depression AOR=3.3 (95% CI: 2.5, 4.4) Transgender Status Aim 1 c

Discussion Physical assault is endemic among Black transgender women Black transgender women need to be a priority population for interventions that address physical assault. Federal laws that prohibit discrimination based on gender identity in the areas of employment, housing, public accommodation, social services and access to credit Interventions designed to address racism and transphobia within the communities Black transgender women live.  4/10 transgender women have been physically assaulted in the past year. To put this number into perspective, just 10% of non-transgender, heterosexual women report LIFETIME adult physical assault. Because the regularity of experiences of physical assault suggests racism and transphobia are a likely source of this violence

Discussion Black transgender women and their general health must be more fully represented in research. Health disparities among Black MSM are amplified among Black transgender women Disentangling these two populations in HIV/AIDS research is necessary Funding research that focuses on the general health of Black transgender is necessary

Limitations and Strengths Cross-sectional data for testing mediation Only explored physical assault Surveyed Black transgender women at Black Pride events Strengths While longitudinal data would have strengthened the results of this study, we are confident in our mediation model as depression and polysubstance use usually follow physical assault The burgeoning literature among transgender persons suggests that transgender individuals experience multiple types and forms of violence. Our analysis only focused on physical assault, and we did not explore how experiencing different and multiple forms of violence manifest within this community. Individuals who attend black pride events may be different than individuals who do not attend black pride events, so our results are not generalizeable to all BTW and BMSM

Conclusions If the epidemic of physical assault continues among Black transgender women in the United States, efforts to address depression and poly-substance use as well as other downstream health outcomes such as HIV incidence and HIV-related health outcomes may prove futile. Interventions