Mediational models linking psychosocial context, mental health problems, substance use, and HIV risk behaviors in transgender women

Abstract

Discrimination and victimization are very common experiences of transgender women. Social marginalization is often linked to poor mental health, substance use, and risky sexual behaviors. HIV prevalence in transgender women in the USA may be as high as 27.7%, and has been estimated at nearly 50 times that of the overall adult population globally. It is in this context that we test structural equation models for the relationships among perceived gender-identity discrimination, internalized anxiety about being transgender (transphobia), mental health problems, illicit substance and alcohol use, and HIV risk behaviors. We tested two mediational models: one that proposes mental health, alcohol, and other substance use as key mediators of sexual risk behaviors, and the other that posits the exchange of sex for money or goods as a key mediator linking mental health and substance use with other risky sexual behaviors. Our results suggest that perceived gender-identity discrimination and internalized transphobia are both significantly related to mental health problems. In turn, in the first model, mental health problems were marginally related to number of sexual partners and sex under the influence of drugs. In addition, alcohol use played a key role in risky sexual behaviors in both models and having sex in exchange for money or goods also played a significant role in the second model. We discuss some of the limitations in the data and analyses that require further research to explore these relationships more carefully.