In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including “fillers”), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women.
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Asscheman, H., T’Sjoen, G., Lemaire, A., Mas, M., Meriggiola, M., Mueller, A., et al. (2014). Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: A review. Andrologia, 46, 791–795.
Baams, L., Jonas, K. J., Utz, S., Bos, H., & Van Der Vuurst, L. (2011). Internet use and online social support among same sex attracted individuals of different ages. Computers in Human Behavior, 27, 1820–1827.
Barrington, C., Wejnert, C., Guardado, M. E., Nieto, A. I., & Bailey, G. P. (2012). Social network characteristics and HIV vulnerability among transgender persons in San Salvador: Identifying opportunities for HIV prevention strategies. AIDS and Behavior, 16, 214–224.
Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. American Journal of Public Health, 103, 1820–1829.
Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57, 254–258.
Brennan, J., Kuhns, L. M., Johnson, A. K., Belzer, M., Wilson, E. C., & Garofalo, R. (2012). Syndemic theory and HIV-related risk among young transgender women: The role of multiple, co-occurring health problems and social marginalization. American Journal of Public Health, 102, 1751–1757.
Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81, 545–547.
Centola, D. (2011). An experimental study of homophily in the adoption of health behavior. Science, 334, 1269–1272.
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health, 91, 915–921.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13, 165–232.
DeVoe, J. E., Fryer, G. E., Phillips, R., & Green, L. (2003). Receipt of preventive care among adults: Insurance status and usual source of care. American Journal of Public Health, 93, 786–791.
Factor, R. J., & Rothblum, E. D. (2008). A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence. Journal of LGBT Health Research, 3, 11–30.
Fletcher, J. B., Kisler, K. A., & Reback, C. J. (2014). Housing status and HIV risk behaviors among transgender women in Los Angeles. Archives of Sexual Behavior, 43, 1651–1661.
Garofalo, R., Deleon, J., Osmer, E., Doll, M., & Harper, G. W. (2006). Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. Journal of Adolescent Health, 38, 230–236.
Gooren, L. J., Giltay, E. J., & Bunck, M. C. (2008). Long-term treatment of transsexuals with cross-sex hormones: Extensive personal experience. Journal of Clinical Endocrinology and Metabolism, 93, 19–25.
Grant, J. M., Mottet, L., Tanis, J. E., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality.
Herbst, J. H., Jacobs, E. D., Finlayson, T. J., McKleroy, V. S., Neumann, M. S., Crepaz, N., et al. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior, 12, 1–17.
Holloway, I. W., Dunlap, S., Del Pino, H. E., Hermanstyne, K., Pulsipher, C., & Landovitz, R. J. (2014). Online social networking, sexual risk and protective behaviors: Considerations for clinicians and researchers. Current Addiction Reports, 1, 220–228.
Hughto, J. M. W., Reisner, S. L., & Pachankis, J. E. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science and Medicine, 147, 222–231.
Hwahng, S. J., & Nuttbrock, L. (2007). Sex workers, fem queens, and cross-dressers: Differential marginalizations and HIV vulnerabilities among three ethnocultural male-to-female transgender communities in New York City. Sexuality Research & Social Policy, 4, 36–59.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. A. (2016). The report of the 2015 US transgender survey. Washington, DC: National Center for Transgender Equality.
Kalichman, S. C., Benotsch, E. G., Weinhardt, L. S., Austin, J., & Luke, W. (2002). Internet use among people living with HIV/AIDS: Association of health information, health behaviors, and health status. AIDS Education and Prevention, 14, 51–61.
Kalichman, S. C., Cherry, C., Cain, D., Pope, H., Kalichman, M., Eaton, L., et al. (2006). Internet-based health information consumer skills intervention for people living with HIV/AIDS. Journal of Consulting and Clinical Psychology, 74, 545–554.
Kurtz, S. P., Surratt, H. L., Kiley, M. C., & Inciardi, J. A. (2005). Barriers to health and social services for street-based sex workers. Journal of Health Care for the Poor and Underserved, 16, 345–361.
Lombardi, E. L. (1999). Integration within a transgender social network and its effect upon members’ social and political activity. Journal of Homosexuality, 37, 109–126.
MacCarthy, S., Reisner, S. L., Nunn, A., Perez-Brumer, A., & Operario, D. (2015). The time is now: Attention increases to transgender health in the United States but scientific knowledge gaps remain. LGBT Health, 2, 287–291.
Mehra, B., Merkel, C., & Bishop, A. P. (2004). The internet for empowerment of minority and marginalized users. New Media & Society, 6, 781–802.
Moore, E., Wisniewski, A., & Dobs, A. (2003). Endocrine treatment of transsexual people: A review of treatment regimens, outcomes, and adverse effects. Journal of Clinical Endocrinology and Metabolism, 88, 3467–3473.
Mustanski, B., Lyons, T., & Garcia, S. C. (2011). Internet use and sexual health of young men who have sex with men: A mixed-methods study. Archives of Sexual Behavior, 40, 289–300.
Nemoto, T., Bödeker, B., & Iwamoto, M. (2011). Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. American Journal of Public Health, 101, 1980–1988.
Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors among male-to-female transgender persons of color in San Francisco. American Journal of Public Health, 94, 1193–1199.
Nuttbrock, L. A., Bockting, W. O., Hwahng, S., Rosenblum, A., Mason, M., Macri, M., et al. (2009). Gender identity affirmation among male-to-female transgender persons: A life course analysis across types of relationships and cultural/lifestyle factors. Sexual and Relationship Therapy, 24, 108–125.
Pinto, R. M., Melendez, R. M., & Spector, A. Y. (2008). Male-to-female transgender individuals building social support and capital from within a gender-focused network. Journal of Gay & Lesbian Social Services, 20, 203–220.
Poteat, T., German, D., & Kerrigan, D. (2013). Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Social Science and Medicine, 84, 22–29.
Poteat, T., Wirtz, A. L., Radix, A., Borquez, A., Silva-Santisteban, A., Deutsch, M. B., et al. (2015). HIV risk and preventive interventions in transgender women sex workers. Lancet, 385, 274–286.
Reback, C. J., & Fletcher, J. B. (2014). HIV prevalence, substance use, and sexual risk behaviors among transgender women recruited through outreach. AIDS and Behavior, 18, 1359–1367.
Reback, C. J., Lombardi, E. L., Simon, P. A., & Frye, D. M. (2005). HIV seroprevalence and risk behaviors among transgendered women who exchange sex in comparison with those who do not. Journal of Psychology & Human Sexuality, 17(1–2), 5–22.
Reback, C. J., Simon, P. A., Bemis, C. C., & Gatson, B. (2001). The Los Angeles transgender health study: Community report. Los Angeles, CA: Friends Research Institute.
Rekart, M. L. (2006). Sex-work harm reduction. Lancet, 366, 2123–2134.
Rice, E., Milburn, N. G., & Monro, W. (2011). Social networking technology, social network composition, and reductions in substance use among homeless adolescents. Prevention Science, 12, 80–88.
Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2013). Nonprescribed hormone use and self-performed surgeries: “Do-it-yourself” transitions in transgender communities in Ontario, Canada. American Journal of Public Health, 103, 1830–1836.
Sanchez, N. F., Sanchez, J. P., & Danoff, A. (2009). Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health, 99, 713–719.
Sevelius, J. M. (2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68, 675–689.
Sevelius, J. M., Patouhas, E., Keatley, J. G., & Johnson, M. O. (2014). Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Annals of Behavioral Medicine, 47, 5–16.
Sevelius, J. M., Reznick, O. G., Hart, S. L., & Schwarcz, S. (2009). Informing interventions: The importance of contextual factors in the prediction of sexual risk behaviors among transgender women. AIDS Education and Prevention, 21, 113–127.
Shapiro, E. (2004). ‘Trans’ cending barriers: Transgender organizing on the internet. Journal of Gay & Lesbian Social Services, 16(3–4), 165–179.
Shelton, J. (2015). Finding a gender home: Gender identity assertion and housing status among unstably housed transgender youth. Paper presented at the Society for Social Work and Research Conference, New Orleans, LA.
Spicer, S. S. (2010). Healthcare needs of the transgender homeless population. Journal of Gay & Lesbian Mental Health, 14, 320–339.
Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14, 170–179.
Styperek, A., Bayers, S., Beer, M., & Beer, K. (2013). Nonmedical-grade injections of permanent fillers medical and medicolegal considerations. Journal of Clinical & Aesthetic Dermatology, 6(4), 22–29.
Sudano, J. J., & Baker, D. W. (2003). Intermittent lack of health insurance coverage and use of preventive services. American Journal of Public Health, 93, 130–137.
Wasserman, S., & Faust, K. (1994). Social network analysis: Methods and applications. Cambridge, UK: Cambridge University Press.
White Hughto, J. M., Murchison, G. R., Clark, K., Pachankis, J. E., & Reisner, S. L. (2016). Geographic and individual differences in healthcare access for US transgender adults: A multilevel analysis. LGBT Health, 3, 424–433.
White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health, 1, 21–31.
Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health, 99, 2289–2295.
Wilson, E., Garofalo, R., Harris, R. D., Herrick, A., Martinez, M., Martinez, J., et al. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS and Behavior, 13, 902–913.
Wilson, E., Rapues, J., Jin, H., & Raymond, H. F. (2014). The use and correlates of illicit silicone or “fillers” in a population-based sample of transwomen, San Francisco, 2013. Journal of Sexual Medicine, 11, 1717–1724.
Xavier, J. M., Bobbin, M., Singer, B., & Budd, E. (2005). A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism, 8, 31–47.
Yang, M.-F., Manning, D., van den Berg, J. J., & Operario, D. (2015). Stigmatization and mental health in a diverse sample of transgender women. LGBT Health, 2, 306–312.
Young, A. M., Boyd, C., & Hubbell, A. (2000). Prostitution, drug use, and coping with psychological distress. Journal of Drug Issues, 30, 789–800.
This study was supported by the National Institute on Drug Abuse, Grant #R21DA037816. Dr. Reback acknowledges additional support from the National Institute of Mental Health (P30 MH58107). Ms. Clark acknowledges funding support from the Graduate Division, UCLA Fielding School of Public Health (Fellowship in Epidemiology, #104733842). Dr. Holloway acknowledges funding support from the California HIV/AIDS Research Program (RP15-LA-007).
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Clark, K., Fletcher, J.B., Holloway, I.W. et al. Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County. Arch Sex Behav 47, 953–962 (2018). https://doi.org/10.1007/s10508-017-1143-x
- Transgender women
- Hormone use
- Social network
- Structural inequality