Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County

Abstract

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.

This is a preview of subscription content, access via your institution.

References

  1. 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.

    Article  PubMed  Google Scholar 

  2. 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.

    Article  Google Scholar 

  3. 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.

    Article  PubMed  Google Scholar 

  4. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57, 254–258.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 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.

    Article  PubMed  Google Scholar 

  8. Centola, D. (2011). An experimental study of homophily in the adoption of health behavior. Science, 334, 1269–1272.

    Article  PubMed  Google Scholar 

  9. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 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.

    Article  Google Scholar 

  11. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 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.

    Article  Google Scholar 

  13. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 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.

    Article  PubMed  Google Scholar 

  15. 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.

    Article  PubMed  Google Scholar 

  16. 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.

    Google Scholar 

  17. 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.

    Article  PubMed  Google Scholar 

  18. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 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.

    Article  Google Scholar 

  20. 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.

    Article  Google Scholar 

  21. 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.

    Google Scholar 

  22. 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.

    Article  PubMed  Google Scholar 

  23. 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.

    Article  PubMed  Google Scholar 

  24. 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.

    Article  PubMed  Google Scholar 

  25. 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.

    Article  PubMed  Google Scholar 

  26. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Mehra, B., Merkel, C., & Bishop, A. P. (2004). The internet for empowerment of minority and marginalized users. New Media & Society, 6, 781–802.

    Article  Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. 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.

    Article  PubMed  Google Scholar 

  30. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 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.

    Article  Google Scholar 

  33. 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.

    Article  Google Scholar 

  34. 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.

    Article  PubMed  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 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.

    Article  Google Scholar 

  38. 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.

    Google Scholar 

  39. Rekart, M. L. (2006). Sex-work harm reduction. Lancet, 366, 2123–2134.

    Article  Google Scholar 

  40. 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.

    Article  PubMed  Google Scholar 

  41. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Sevelius, J. M. (2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68, 675–689.

    Article  PubMed  Google Scholar 

  44. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Shapiro, E. (2004). ‘Trans’ cending barriers: Transgender organizing on the internet. Journal of Gay & Lesbian Social Services, 16(3–4), 165–179.

    Article  Google Scholar 

  47. 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.

  48. Spicer, S. S. (2010). Healthcare needs of the transgender homeless population. Journal of Gay & Lesbian Mental Health, 14, 320–339.

    Article  Google Scholar 

  49. Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14, 170–179.

    Article  Google Scholar 

  50. 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.

    Google Scholar 

  51. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Wasserman, S., & Faust, K. (1994). Social network analysis: Methods and applications. Cambridge, UK: Cambridge University Press.

    Book  Google Scholar 

  53. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  55. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 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.

    Article  Google Scholar 

  59. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Young, A. M., Boyd, C., & Hubbell, A. (2000). Prostitution, drug use, and coping with psychological distress. Journal of Drug Issues, 30, 789–800.

    Article  Google Scholar 

Download references

Acknowledgements

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).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kirsty Clark.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

Keywords

  • Transgender women
  • Hormone use
  • Social network
  • Structural inequality