8/23/2012
Improving the Health of Trans Communities: Findings from the Trans PULSE Project
Jake Pyne, Greta Bauer, Nik Redman and Robb Travers, for the Trans PULSE Project Team
Trans Health Advocacy Summit 11 August, 2012 London, Ontario, Canada
The Trans PULSE Project : Background and Methods
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Community-based mixed-methods study exploring how social exclusion impacts the health of trans people in Ontario.
Trans is defined broadly, and may include those who identify as transgender, transsexual, two-spirit trans, transitioned, bigender, genderqueer, or simply man or woman.
History of Trans PULSE
• Sherbourne Health Centre started LGBT health program in Toronto in 2002. Trans people across Ontario sought these services. Nowhere else to refer people. • Advocacy Strategy: Collect evidence and make a strong case for creating access to health services. • In 2004 Sherbourne partnered with community members and received series of small grants to begin work in 2005. • Project became “Trans PULSE” in 2006 with community soundings and first major grant application.
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Our Guiding Principles:
• conduct research that is respectful
• build capacities for research
• use the highest quality methods possible
• ensure maximum positive impact
• ensure meaningful involvement
Community Control Model
• Community members selected academic partners • Terms of Reference stipulating trans majority among Investigators • Trans-majority for all major decision making • Community-Engagement Team (16 members of trans communities) • Community Development Coordinator Role • Research that builds community
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Qualitative Phase 1:
• 2006, three “Community Soundings” were held in Guelph, Ottawa and Toronto with over 80 members of the trans community • Open-ended questions re: experiences with using services, health care, discrimination, etc. • Findings used to develop theoretical paper on how erasure impacts health care access for trans people • Findings used to guide the questions asked on the Trans PULSE survey
Quantitative Phase 2:
• In 2009 Trans PULSE launched 87 page survey • Survey items based heavily on community knowledge • Quantitative = measurement (how much? how many?) • Used respondent-driven sampling
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RespondentRespondent--DrivenDriven Sampling (RDS)
• Findings from trans health studies are not always taken seriously by policy makers • RDS is a method which uses a unique mathematical model to produce results that are harder to dismiss • Begin with “seeds” (initial participants) who complete the survey and pass it to 3 others, who then also pass it to 3 others, etc. • Special statistical methods allow for estimating percentages for trans people in Ontario, rather than the percent of participants
Trans PULSE Video
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RespondentRespondent--drivendriven sample (n=433)
# of Ontario Trans People Known
= 0-1 = 2-4 = 5-9 = 10-19 = 20-49 = 50-99 = 100+
Who are Trans People in Ontario?
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Coleman, Bauer, Scanlon et al. Challenging the binary: gender characteristics of trans Ontarians. Trans PULSE e-Bulletin 2011; 2(2)
Sexual Orientation Other 8% Two Spirit 9% Bisexual or Pansexual 30% Straight or Heterosexual Lesbian 30% 14%
Queer 31% Asexual Gay 5% 11% Questioning 13%
Bauer, Boyce, Coleman et al. Who are trans people in Ontario? Trans PULSE e-Bulletin 2010;1(1)
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Bauer, Boyce, Coleman et al. Who are trans people in Ontario? Trans PULSE e-Bulletin 2010;1(1)
Age First Aware that Gender did not Match Body
59% Under Age 10 21% Age 10 -14 13% Age 15 -19 7% Age 20 -29 1% Age 30 and over
Coleman, Bauer, Scanlon et al. Challenging the binary: gender characteristics of trans Ontarians. Trans PULSE e-Bulletin 2011; 2(2)
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We Are More than Just Trans
Intersex 6% Living with Racialized Disability or 23% Chronic Illness 55%
Parents Aboriginal 27% 7% Born Outside Canada 19%
• Bauer, Travers, Scanlon, Coleman. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada. BMC Public Health 2012;12:292. • Coleman, Bauer, Scanlon et al. Challenging the binary: gender characteristics of trans Ontarians. Trans PULSE e-Bulletin 2011; 2(2). • Bauer, Boyce, Coleman et al. Who are trans people in Ontario? Trans PULSE e-Bulletin 2010;1(1). • Warner A. Prevalence and risk factors for underhousing among trans people in Ontario. MSc Thesis. Western University, 2010.
Discrimination
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Racism impacts trans people Some examples:
Partners have paid more Have been harassed by police attention to your race or because of race or ethnicity ethnicity than to you as a person 40 40
30 30
20 20
10 10
0 0 Aboriginal Non-Abor. Non-Abor. Aboriginal Non -Abor. Non -Abor. White Racialized White Racialized
Marcellin RL. Self-reported racism, transphobia, their intersection and impact on past-year HIV- related sexual risk behaviour. MSc thesis, The University of Western Ontario, 2012.
Racism also occurs within trans communities
• Occurs in trans Have been uncomfortable communities due to in trans spaces because of non-inclusion of race or ethnicity colour/cultural and 40 language diversities 30
20
10
0 Aboriginal Non-Abor. Non-Abor. White Racialized
Marcellin RL. Self-reported racism, transphobia, their intersection and impact on past-year HIV- related sexual risk behaviour. MSc thesis, The University of Western Ontario, 2012.
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Transphobia
• Nearly all trans people have had some trans-specific negative experiences from family, service providers, police or others in the broader community • Horizontal hostility (which may be related to internalized transphobia) causes a lack of unity within trans communities • Travers R, Pyne J, Bauer G, et al. Community control in CBPR: Challenges experienced and questions raised from the Trans PULSE Project. Manuscript under revision.
Racism and transphobia interact to impact the health of racialized trans people
Impact of an increase in Impact of an increase in transphobia on sexual risk racism on sexual risk depends on level of racism depends on level of transphobia 15 15
10 10 ODDS RATIO FOR RATIO ODDS 5-UNIT INCREASE 5-UNIT 5 5
NO NO EFFECT 0 0 EFFECT None Low/Mod High None Low/Mod High RACISM TRANSPHOBIA
Marcellin RL. Self-reported racism, transphobia, their intersection and impact on past-year HIV- related sexual risk behaviour. MSc thesis, The University of Western Ontario, 2012.
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Barriers to employment: References and transcripts with current name and gender?
100 80 28 N/A 58 No % 60 Yes 40 57 20 30
0 Bauer, Nussbaum, Travers et al. We’ve got work to do: Workplace Transcripts References discrimination and employment challenges for trans people in Ontario. Trans PULSE e-Bulletin 2011, 2(1). 1-3.
Ever experienced employment discrimination because trans?
100 80 No 60 Unsure % 40 32 Yes 15 20 17 18 13 0 Declined job Turned Fired Bauer, Nussbaum, Travers et al. We’ve offer down for job got work to do: Workplace discrimination and employment challenges for trans people in Ontario. Trans PULSE e-Bulletin 2011, 2(1). 1-3.
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If transitioned in workplace, how accepting were coworkers?
40 35 30 25 20 15 Bauer, Nussbaum, Travers 10 et al. We’ve got work to do: Workplace 5 discrimination and employment challenges 0 for trans people in Always Most of Half of Less than Never Ontario. Trans PULSE e- time time half Bulletin 2011, 2(1). 1-3.
Access to Medical Care
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Non-transition-related care Transition-related care • Trans people have the same range of • Trans people may or may not require medical conditions as cis people, access to medical transition-related though care within cisnormative care gendered systems may be complicated by structural and information barriers
Completed (by own criteria)
In process
Planning, but not begun
Not planning to
Concept does not apply
Not sure Medical Transition (hormones and/or surgeries)
Bauer, Hammond, Travers, et al. “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. JANAC 2009;20(5):348-361.
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Emergency care
• 21% of trans people reported having avoided the emergency room when they needed it, because they were trans. • 2/3 of those who used the emergency room while presenting in their felt gender reported having to educate their emergency care provider regarding trans issues.
• Paper in preparation.
Unmet need for transition care: large backlog and continued access issues
Hormones Surgeries • 53% had ever used hormones • 20% have been denied a hormone prescription • Rotondi, Bauer, Scanlon, et al. Non- prescribed hormone use and self-performed surgeries. Manuscript under review. Other needs • Voice therapy • Relationship and sex therapy • Hair removal • Non-OHIP-funded surgeries (e.g. Bauer, for Trans PULSE. Unmet need for OHIP-funded sex reassignment tracheal shave) surgeries: A report prepared for the MOHLTC of Ontario. 16 August, 2010.
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Why is access important?
Medical Transition Status and Past-year Suicidality
Attempted Suicide Seriously Considered Suicide
46 50 36 40 20 30 27 23
20% 18 10 3
0 1 Not planning or N/A Planning but not begun In process Completed* *Completing a medical transition was self-defined, and involved different Paper in combinations of hormones and/or surgery for different people preparation.
Coping and working for access
• “Do-it-Yourself” transitions • 14% of Ontario trans people have used non-prescribed hormones • 5 of 433 participants had self-performed surgeries, or attempted to, during the 10-year period in which SRS was delisted
• Rotondi, Bauer, Scanlon, et al. Non-prescribed hormone use and self-performed surgeries: “Do-it- yourself” transitions in Ontario, Canada’s transgender communities. Manuscript under review. • Trans people were instrumental in getting SRS re-listed through OHIP in 2008, and in continued work to improve access • On an individual level, trans people educate doctors, and build informal referral networks for “good” doctors
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Some things providers can do: A start
Bauer, Hammond, Travers, et al. “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. JANAC 2009;20(5):348-361.
Sexual Health and Behaviours
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Some key findings
• High proportion of trans people (25% FTM, 50% MTF) did not have partner sex within the last year • 46% had never been tested for HIV • 15% of both FTM & MTF had done sex work
Bauer, Travers, Scanlon, Coleman. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada. BMC Public Health 2012:12:292.
HIVHIV--relatedrelated sexual risk, by gender spectrum
FTM Spectrum MTF Spectrum 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 No risk (no sex) Low/Moderate High risk No risk (no sex) Low/Moderate High risk risk risk Bauer, Travers, Scanlon, Coleman. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada. BMC Public Health 2012:12:292.
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If we further break down the FTM guys by sexual orientation…
FTM – GB-MSM FTM – Straight 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 No risk (no sex) Low/Moderate High risk No risk (no sex) Low/Moderate High risk risk risk
Bauer, Redman, Bradley. Gay, bi and MSM trans guys: No assumptions! A report prepared for the Gay Men’s Sexual Health Summit, 28 February, 2012.
Types of partners (current and past partners): FTM spectrum
70
60
50 trans men
40 non-trans men 66 30 % 45 20 trans women 32 10 18 non-trans women 11 0 Bauer, Travers, Scanlon, genderqueer Coleman. High persons heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada. BMC Public Health 2012:12:292.
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Types of partners (current and past partners): MTF spectrum
70
60
50
40 68 trans men % 30 non-trans men 20 40 trans women
10 19 non-trans women 9 12 genderqueer persons 0 Bauer, Travers, Scanlon, Coleman. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada. BMC Public Health 2012:12:292.
Demographics: types of partners (current and past)
trans men non-trans men trans women non-trans women genderqueer persons
80 70 60 50 % 40 30 20 Bauer, Travers, Scanlon, 10 Coleman. High 0 heterogeneity of HIV-related non-indigenous white indigenous non-indigenous sexual risk among racialized transgender people in Ontario, Canada. BMC Public Health 2012:12:292.
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Sexual behaviours, past year: FTM spectrum
70
60
50
40 % 30 60 61 57 55
20 Bauer, Travers, Scanlon, 28 26 10 Coleman. High heterogeneity of HIV-related sexual risk among 0 transgender people in received gave oral receptive insertive receptive insertive BMC oral anal anal genital genital Ontario, Canada. Public Health 2012:12:292.
Sexual behaviours, past year: MTF spectrum
70
60
50
40 % 30
45 20 37 29 32 Bauer, Travers, Scanlon, 10 Coleman. High 14 16 heterogeneity of HIV-related sexual risk among 0 transgender people in received gave oral receptive insertive receptive insertive BMC oral anal anal genital genital Ontario, Canada. Public Health 2012:12:292.
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Demographics: Sexual behaviours, past year
received oral sex gave oral sex
receptive partner in anal sex insertive partner in anal sex
80 receptive partner in genital sex insertive partner in genital sex 70 60 50 % 40 30
20 Bauer, Travers, Scanlon, 10 Coleman. High heterogeneity of HIV-related 0 sexual risk among non-indigenous white indigenous non-indigenous transgender people in racialized Ontario, Canada. BMC Public Health 2012:12:292.
FTM spectrum: FluidFluid--exposedexposed sexual behaviours, past yr
8 7 6 5 4 % 7 3 2 Bauer, Travers, Scanlon, 1 Coleman. High 0 1 heterogeneity of HIV-related sexual risk among receptive anal insertive anal receptive insertive genital transgender people in sex sex genital sex sex Ontario, Canada. BMC Public Health 2012:12:292.
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MTF spectrum: FluidFluid--exposedexposed sexual behaviours, past yr
18
16
14
12
10
8 16
6
4 Bauer, Travers, Scanlon, 2 4 4 Coleman. High 3 heterogeneity of HIV-related 0 sexual risk among High-risk High-risk High-risk High-risk transgender people in receptive anal sex insertive anal sex receptive genital insertive genital Ontario, Canada. BMC sex sex Public Health 2012:12:292.
HIV testing
FTM Spectrum MTF Spectrum
60
50
40 % 30
20 Bauer, Travers, Scanlon, 10 Coleman. High heterogeneity of HIV-related 0 sexual risk among <6 mos ago 6 mos to < 1 1 yr to < 2 2+ years ago never HIV transgender people in yr ago yrs ago tested Ontario, Canada. BMC Public Health 2012:12:292.
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Ever tested for HIV?
90 Aboriginal trans people 80 were significantly more 70 likely to have ever been 60 tested than either non- 50 Aboriginal group 40 Among non-Aboriginal 30 groups, racialized trans 20 people were significantly 10 less likely to have ever 0 been tested than white Aboriginal Non-Aboriginal Non-Aboriginal racialized white trans people.
Needle sharing and HIV risk
• Despite reports from the U.S. of high prevalences of needle sharing for hormones, we found no such evidence for Ontario. • This is likely do to the legality and funding of needle exchanges, pharmacy purchases of needles, and no- fee doctors visits.
• Travers, Coleman, Bauer, Scanlon. Hormone, silicone and drug injection: Assessment of infection-related risk among transgender people in Ontario, Canada. Manuscript under review.
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Mental Health
Suicide thoughts and attempts, lifetime
100 80 No % 60 Yes 77 40 50 43 20 0 Seriously Considered Attempted considered because trans Scanlon, Travers, Coleman et al. Ontario’s trans communities and suicide: transphobia is bad for our health. Trans PULSE e-Bulletin 2010, 1(2). 1-2.
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Trans youth and suicide, past year
50 45 40 35 30 Youth 16 -24 25 % 47 Age 25+ 20 15 27 10 19 5 7 0 Seriously considered Attempted
Scanlon, Travers, Coleman et al. Ontario’s trans communities and suicide: transphobia is bad for our health. Trans PULSE e-Bulletin 2010, 1(2). 1-2.
Transphobic harassment/violence and suicide, past year
50 45 40 35 30 No transphobic % 25 47 violence 20 Harassment or 15 33 26 29 threat 10 Physical or sexual 5 4 8 0 assault Seriously considered Attempted
Scanlon, Travers, Coleman et al. Ontario’s trans communities and suicide: transphobia is bad for our health. Trans PULSE e-Bulletin 2010, 1(2). 1-2.
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Depression
• Depression was measured using a standard 20-question scale called the Center for Epidemiologic Studies Depression Scale (CES-D) • Being “depressed” on the CES-D means having significant levels of depressive symptoms, not necessary being clinically depressed
Rates of reporting depressive symptoms
• MTFs - 61% • FTMs – 66%
• Rotondi , Bauer, Travers et al. Depression in male-to-female transgender Ontarians: results from the Trans PULSE project. Can J Comm Mental Health 2011;30(2):113-133. • Rotondi, Bauer, Scanlon et al. Prevalence of and risk and protective factors for depression in female-to- male transgender Ontarians: Trans PULSE project. Can J Comm Mental Health 2011:30(2):135-155.
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Persons on the MTF spectrum were less likely to be depressed if...
Compared to MTFs who Compared to all MTFs were similar on other factors • Employed full-time (vs. • Employed full-time (vs. unemployed) unemployed) • Living in Toronto • Living in Toronto • Having more support for identity • Having more social support • Not reporting childhood abuse • Experiencing less transphobia • Little involvement with community • Having postsecondary degree organizations (any community) • Not always (or almost always) Rotondi , Bauer, Travers et al. Depression in male-to- passing female transgender Ontarians: results from the Trans PULSE project. Can J Comm Mental Health 2011;30(2):113-133.
Persons on the FTM spectrum were less likely to be depressed if...
Compared to all FTMs Compared to FTMs who • Experiencing less transphobia were similar on other factors • Having greater sexual satisfaction • Experiencing less transphobia • Not in the “planning but not begun” • Having greater sexual satisfaction transition status group • Not in the “planning but not begun” • No reported major mental health transition status group diagnoses • Having more social support • Having more support for identity • Currently using hormones Rotondi, Bauer, Scanlon et al. Prevalence of and risk and protective factors for depression in female-to-male • Had any trans surgery transgender Ontarians: Trans PULSE project. Can J Comm Mental Health 2011:30(2):135-155.
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Impact of parental support, trans youth age 1616--2424
Very supportive parent(s) Somewhat supportive parent(s) Unsupportive parent(s) 80 70 60 50 40 30 20 10 0 Satisfied with life VG/Excellent physical VG/Excellent mental health health Report in preparation.
Impact of parental support, trans youth age 1616--2424
Very supportive parent(s) Somewhat supportive parent(s) Unsupportive parent(s) 90 80 70 60 50 40 30 20 10 0
Depressive symptoms Past-yr suicide attempt Report in preparation.
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What can be done?
• Workers must be able to respond to specific issues facing trans people: • Crisis centre staff • Mental health workers • Youth-serving agencies and school officials • Parents must be aware that their strong support can have positive impacts on their trans children
Moving Forward
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Information we are now working on producing or getting out …
• Racism and transphobia • Qualitative study: Trans • Primary care access people living with HIV • Emergency room access • Plus: • “Do it yourself” transitions • Sharing what we have • HIV testing learned about our methods • Suicide prevention with other researchers • Violence • Challenges in moving from community involvement to • Housing community ownership and • Parental support control of research
Strategy: Getting important bits out quicker through EE--BulletinBulletinss
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Strategy: Targeted reports
Strategy: Academic papers
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Our part in making it better: Knowledge, policy change and social change
• Undoing erasure through making community experience visible • Barriers to health care, transition-related and general care, employment discrimination, social support, identity documents, sexual health and relationships, many other areas • Direct KTE and advocacy input • Policy forum, meetings with (and reports to) MOHLTC, politicians, presentations to organizations • Indirect KTE and advocacy • Website, results e-mail list to over 600 people, Resource List • Newly redesigned website: http://www.transpulseproject.ca
Trans PULSE Project Team (2004 --present)present)
Steering Committee/ Current Contributors Past Contributors Investigators Kaitlin Bradley Scott Anderson Nicole Nussbaum Todd Coleman Nael Bhanji Evana Ortigoza Greta Bauer Maddie Deutsch Michelle Boyce Jamie Pandit Robb Travers Matthias Kaay J.R. Caughlin Yasmin Persad Rebecca Hammond Carys Massarella Starr Daniels Catherine Purdie Anjali K Roxanne Longman Marcellin Melisa Dickey Tyson Purdy-Smith Nik Redman Lauren Munro Adrian Edgar Rupert Raj Anna Travers Caleb Nault Broden Giambrone Will Rowe Jake Pyne Nooshin Khobzi Rotondi Karin Hohenadel Kyle Scanlon Alex St. John Elizabeth James Sydney Tam Ayden Scheim Michelle Le-Claire Ann Teve Participants Sam Talbot Matt Lundie Kenji Tokawa Amardeep Thind Treanor Mahood-Greer Brady Yu Devi McCallion 89 Community Soundings Andrew Warner Mason McColl 433 Survey Xuchen Zong
Funders
Phase I Phase II
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Contact information [email protected] http://www.transpulseproject.ca
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