1. 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

2. 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,

3. 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

4. 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

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

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

7. 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

8. 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.

9. 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.

10. 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

11. 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’

12. 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.

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

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

15. 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

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

17. 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

18. 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.

19. 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    

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

21. 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%

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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