GLOBAL HEALTH NEEDS OF TRANSGENDER PEOPLE Stefan Baral, MD MPH
Acknowledgements
The transgender men and women across the world who participate in these studies given significant risks and limited personal benefits The community groups that make great personal and professional sacrifices to serve the unmet health and advocacy needs of those most marginalized in the HIV response Contributions of Ideas and New Data
Sari Reisner, Sam Winter, Tonia Poteat, Kevan Whylie, Claire Holland, Ashley Grosso, Paul Semugoma, Chris Beyrer, and others
Outline
Health Issues Affecting Transgender People Conceptual Framework of Health Vulnerabilities among Transgender People Structural
Determinants of Health
Health Care Interventions Available
data Mathematical Model
Models of Care Delivery for Transgender People Moving Forward Key Themes
Transgender Global Disease Burden Systematic Review 2008-2014
116 studies 30
countries 95 Definitions of Transgender Persons 981 health-related outcomes Mental
health Sexual and reproductive health Substance use Violence/victimization Stigma and Discrimination General Health
Transgender Health Research by Assigned Sex at Birth 60
Number of Data Points (n)
50
48
40
30 20
20
16 9
10
0
23
Male only
Female only
Male & Female (disaggregated)
Male & Female (not disaggregated)
Not specified
Assigned Sex at Birth
Reisner et al, Poteat, Baral., Lancet Special Issue, in press
Global Distribution of Transgender Health Research
Reisner et al, Poteat, Baral., Lancet Special Issue, in press
Population Studies Yielding Prevalence Data for Transgender People Author, Date, country
Sample
Conron, 2012, USA
28662 Adults
Glen and Hurrell, 2012, UK
Measure
Prevalence Data Birth Assigned Males (%)
Birth Assigned Females
All
Identification as Transgender
0.5
0.4
0.5
10039 Adults
Identification as other gender or in another way
0.6
0.4
0.5
Clark, 2014, New Zealand
8166 High School Students
Identification as transgender
1.3
1.2
1.2
Kuyper and Wijsen, 2014, Netherlands
8064 Adults
Identification gender spectrum
1.1
0.8
0.9
Van Caenergen, 2015, Belgium
1832 Adults
Identification gender spectrum
0.7
0.6
0.6
Winter, et al, Lancet Special Issue, in press
Global Health Burden: Six Health Outcome Categories in Transgender Health (n=981 Data Points), 2008-2014 8 350
Number of Data Points (n)
300
303
250 219 193
200 150
105 100
93 68
50 0
Mental Health
Sexual and Reproductive Health
Substance Use
Violence/ Victimization Health Outcome Category
Stigma/ Discrimination
General Health
Reisner et al, Poteat, Baral., Lancet Special Issue, in press
Burden of Mental Health among Transgender Youth 10
Percent (%)
Retrospective Cohort using EMR N=180, age 12-29, 2001-2010 Matches on multiple characteristics to non-transgender youth
60 Transgender Youth
Non-Transgender Youth
50 40 30 20 10 0
Depression
Anxiety
Suicide Ideation
Suicide Attempt
Mental Health (MH)
Self-Harm
Outpatient MH Services
Reisner et al., 2015 in J Adolescent Health
Inpatient MH Services
Burden of Mental Health among Transgender Youth
Reisner et al., 2015 in J Adolescent Health
Sexual and Reproductive Health Outcomes Puberty
Sex Work
Other (BV, PCOS, anal tear)
Viral Hepatitis
STI-related
HIV 0
Series1
10
20
30
HIV
STI-related
Viral Hepatitis
80
83
18
40
50
Other (BV, PCOS, anal tear) 5
60
70
80
Sex Work
Puberty
23
10
90
Reisner et al, Poteat, Baral., Lancet Special Issue, in press
HIV Prevalence among Transgender Women 2001-2011
Results
The pooled global HIV prevalence was 19.1% (95% CI 17.4-20.7) In 7,197 transgender women from 10 LMIC, HIV prevalence was 17.7%(95%CI 15.6-19.8) In 3,869 transgender women from 5 HIC, HIV prevalence was 21.6%(95% CI 18.8-24.3)
HIV Prevalence Data among transgender women compared to all adults
Baral et al., Lancet Infectious Diseases, 2013
Burden of HIV among Transgender Women
Pooled OR for HIV infection among transgender women compared to other reproductive people
48.8 (95% CI 31.2-76.3)
Source: Baral, et al. Worldwide Burden of HIV among Transgender Women The Lancet ID. 2013
Average HIV Prevalence Among Transgender Women by Region 50% 45% 40%
HIV Prevalence
35% 30% 25% 20% 15% 10% 5% 0%
North America (n=25)
Central and South America (n=6)
Africa (n=0)
Europe (n=3)
South and South East Asia (n=6)
Region (number of studies included)
Oceania (n=1) Multi-region (n=2)
Transgender Women across SubSaharan Africa
Very rare for people to identify as transgender, but more common to identify as women using two-step gender assessment in studies focused on gay men and other men who have sex with men (MSM) 16% In Burkina Faso 19% In Malawi 25.5% in Swaziland (aOR for HIV 3.96 [1.66-9.43]) 8% In Lesotho (p