Understanding Gender Minority Stress and Resilience Among Transgender and Gender-Expansive Youth and Emerging Adults and Their Relationship to PrEP Intentions

Background/Purpose:

The population of transgender and gender-expansive youth/emerging adults ages 13-24 years (i.e., gender nonbinary, non-conforming, or genderqueer) is large and growing. These younger people experience a disproportionate risk for HIV, yet their rates of preexposure prophylaxis (PrEP) uptake to prevent HIV are the lowest of any key risk group in the United States (<10%). Still, factors that promote or impede PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stress and resilience, including proximal and distal stressors, and behavioral responses to stress (i.e., heavy substance use) on PrEP outcomes among diverse transgender and gender-expansive youth/emerging adults (TGE-YEA) who evidence HIV risk.

Methods:

Quantitative data were drawn from the CDC’s 2018 Survey of Today’s Adolescent Relationships and Transitions (START) study, a national, cross-sectional online survey that included TGE-YEA for whom PrEP is indicated (N=929). We developed a conceptual model grounded in gender minority stress and resilience theory and mapped START survey items onto it, which includes distal (family rejection and medical discrimination) and proximal (internalized transphobia and perceived stigma) stress, heavy substance use, and background factors (e.g., race/ethnicity, socioeconomic barriers). Resilience was measured as a latent construct with five gender affirmation indicators. We examined factors related to PrEP intentions, the primary outcome, using structural equation modeling. Direct effects were estimated using Mplus 8.9.

Results:

The majority of participants were between 18-24 years of age (68%). 46% identified as trans-female, 28% as trans-male, 26% as gender-expansive, and 42% identified as Black and/or Latinx. Discrimination in medical settings was associated with a 49% increase in the odds of internalized transphobia (OR=1.49, 95% CI [1.10, 2.01], p= 0.010). Family rejection was associated with a 137% increase in the odds of perceived stigma (OR=2.37, 95% CI [1.75, 3.20], p= <0.001), while medical discrimination was associated with a 51% increase (OR=1.51, 95% CI [1.11, 2.06], p= 0.009). Additionally, stress factors were not significantly associated with the odds of heavy substance use, after controlling for background variables. However, for every one-SD increase in resilience, the odds of reporting heavy substance use decreased by 47% (OR=0.53, 95% CI [0.43, 0.66], p= <0.001). Moreover, for every one-SD increase in resilience, the odds of reporting intentions to use PrEP increased by 33% (OR=1.33, 95% CI [1.04, 1.7], p= <0.02). Also, heavy substance use was associated with a 54% decrease in the odds of PrEP intentions among the sample (OR = 0.46, 95% CI [0.31, 0.69], p= <0.001).

Conclusions/Implications:

This study underscores the importance of addressing heavy substance use among TGE-YEA as a potential barrier to PrEP uptake, a critical tool for HIV prevention. The significant negative association between heavy substance use and PrEP intentions highlights the need for further research to investigate this complex relationship and identify effective strategies to improve PrEP outcomes among this population. Also, future studies could explore the potential benefits of social support and resilience-focused interventions in reducing internalized transphobia and perceived stigma, improving overall health outcomes, and increasing PrEP uptake among TGE-YEA.