Macro-Level Community Violence Against Transgender Women: Improving Health in the Context of Structural and Political Violence in Lebanon

Background and Purpose

HIV risk and mental health morbidity are disproportionately high among transgender women in Lebanon. Experiences of violence negatively impact sexual and mental health. In addition to gender-based, family, and community violence, many transgender women in the Middle East, as well as in other settings, experience violence that extends beyond the community level to structural and political violence. Forced migration, country expulsion, profiled detainment and arrest, cancelled asylum, and war event exposure are examples of structural and political violence that impact transgender women in Lebanon. The purpose of this study was to culturally adapt and pilot test a peer-facilitated group intervention for use among transgender women in Lebanon. The adapted six-week intervention, ‘Baynetna,’ seeks to mitigate HIV risk and mental health symptoms through facilitating gender affirmation and community connectedness among transgender women. We explored the intervention’s effect on hypothesized mechanisms of action and hypothesized that war event exposure would be associated with mental health symptoms and sexual health behavior.

Methods

The intervention was adapted to the Lebanese context by using focus group discussions, interviews, and community advisory board meetings. ‘Baynetna’ was then pilot-tested for preliminary feasibility, acceptability, and preliminary impact. Each weekly session included a shared meal, one-on-one check-ins with staff, and discussions about one of the following topics: Gender Affirmation; Self-Esteem and Transphobia; Safer Sex Work, Safer Dating, and Pleasure; HIV and Other STIs; and Family Acceptance / Rejection and Violence. Baseline, 1-, and 3-month follow-up data were collected and analyzed for associations between war event exposure and health outcomes.

Results

Although not powered to detect significant associations in the pilot test, data suggest that participants’ (N=16) exposure to war events moderated intervention impact. A significant decrease in anxiety from baseline to 1-month post-test was moderated by war event exposure (p=0.0036); at three months, this association approached significance (p=0.098). Similarly, those who screened positive for PTSD had higher war exposure scores (p=0.14) and higher war exposure scores were associated with more depression symptoms (p=0.093). Higher war event exposure also approached significance in its relationship with HIV prevention; higher levels of war exposure were associated with more condomless receptive anal intercourse in the last 3 months (p=0.14). Results showed a significant association between high community connectedness and low depression at 3-month post-test (p=0.037). An association between PTSD symptoms and low social cohesion approached significance (p=0.071).

Conclusions and Implications

Our results are aligned with previous research from within the region among other populations that indicate the importance of building community resilience in efforts to ameliorate mental health impacts of war exposure through group interventions. The results confirm that war event exposure is associated with transgender women’s sexual health, mental health, and the intervention’s impact. Further research is necessary; next steps include a larger-scale study with a comparison control group to establish feasibility, acceptability, and efficacy followed by a multi-site trial within the region and/or among countries impacted by war. This was the first NIH-funded study to address health disparities among transgender women in the Middle East.