TRANS-FEMALE YOUTH, DEVELOPMENT, AND HIV RISK Erin C. Wilson, DrPH- San Francisco Department of Public Health,

What we know  Trans-female youth are at high risk for HIV  Sample HIV prevalence rates of 19% and 22% (Wilson, 2009; Garofalo, 2006)  In San Francisco, there is a rise in AIDS diagnoses among transfemales under 30

Contextual factors for HIV risk Mental health Social isolation Economic marginalization Incarceration Health care needs Misperceptions of risk Abuse  Gender identity development and correlates? Adults factors shared by youthUnique to youth

Gender identity formation among children Gender identity is typically developed in three stages:  Construction (ages 0–5 years)  Consolidation (ages 5–7 years)  Integration (ages 7 years and up)

Transgender identity adds additional burden DissonanceExplorationDisclosures *Identity resolution * Seth Pardo, Cornell

What all youth need to thrive  Physical and psychological safety  Appropriate structures  Supportive relationships  Connectedness, caring, support and responsiveness  Opportunities to belong and for meaningful inclusion  Positive social norms  Support for efficacy and mattering that includes enabling, responsibility and meaningful challenges  Opportunities for skill building  Integration of family, school and community efforts Eccles et. al., 2002

 Longitudinal study of trans-female youth in the San Francisco, CA Bay Area  Phase I.  8 focus group discussions conducted with trans-female youth ages to investigate of protective factors that promote resilience *Study funded by the National Institute of Mental Health

Challenges trans-female youth face in gender identity development  Self acceptance and ability to come out  Models for *authentic transitioning and reliable sources of information on gender  Difficulty finding sexual partners  Trauma from gender- related violence and harassment  Accessible medical services to support gender identity development  Lack of familial support  Lack of reliable information and institutional support in schools IndividualStructural

HIV risks may be related to development and intersecting risks Race/EthnicityYouth HIV Sexual Behavior Youth accounted for 39% of all new infections in 2009 Data from 2009 show that African Americans accounted for 50% of all HIV infections MSM account for 49% of the US population living with HIV

Negative developmental experiences related to intersections & trans identity put transyouth at risk for….  Low self esteem  Negative self-image  Physical Violence (a precursor or outcome)  Mental health issues- notably depression, but some evidence of PTSD  Suicide  ??

Poor outcomes identified in TRYP data Individuals FactorsStructural Factors Substance Use (90%) used)Job discrimination (49%) Homelessness (43%)Dropped out of school due to gender discrimination (24%) Victimization by partner (35%) Incarceration (52% have ever been incarcerated) Institutionalization (26%)

HIV positive Youth  The seroprevalence rate among those who ever engaged in sex work was 23.2% compared to 5.9% among those who never engaged in sex work (p=0.0375)

*p-value Sex Work – Youth Sex work- TRYP study 2007

What are factors that differentiate youth with a history of sex work? Higher likelihood of having HIV (23% vs. 6%). Lower educational attainment More homelessness More likely to have been incarcerated More likely to have been abused by a partner Have less overall social support More likely to be victimized in the community More likely to have experienced discrimination in school environments More likely to have been committed to inpatient facilities

Protective Factors that promote healthy development – SHINE study  Support  Connectedness to parents  Friends are hard to come by but critical  Jobs  Opportunity for responsibility  Skill building  Access to gender-related care  Hormones and laser treatment are key for those starting to transition  breast augmentation critical for older youth  Independence/Distance from trans community  *YouTube and other places in the blogosphere  Stories of transitioning and other information  Decreased isolation  Jr. college and university environment Typical of all young peopleUnique to trans youth

Gender-related needs must also be met in HIV prevention for trans-female youth Healthy gender identity developme nt Mitigation of structural risks Supports- parents, schools, peers, medical care HIV prevention

Existing Interventions/Programs Tranny Rockstar Project abstract

State of Prevention Science in HIV  Knowing one’s HIV status  PrEP  Treatment and Viral load suppression

What we need to know  Youth development model for transgender youth  Interventions possible within a paradigm of treatment as prevention?  What supports are necessary and essential to promoting healthy development among transyouth  Chicken or Egg?  Determine which precursors put youth at most risk  Determine most critical supports that can mitigate the effect of deleterious precursors  Identify resilience and build upon it in the development of interventions