社区英文1.docx
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社区英文1.docx
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社区英文1
JournaloftheAssociationofNursesinAIDSCare
Volume20,Issue5,September–October2009,Pages387–397
TransgenderHealthandHIVCare
EditedByCarol"Pat"PatsdaughterandJ.CraigPhillips
Feature
HIVPreventionandPrimaryCareforTransgenderWomeninaCommunity-BasedClinic
∙RitaM.Melendez,PhD,MSAuthorVitae,
∙RogérioM.Pinto,PhDAuthorVitae
Availableonline2September2009
∙http:
//dx.doi.org/10.1016/j.jana.2009.06.002,HowtoCiteorLinkUsingDOI
∙Permissions&Reprints
Male-to-femaletransgenderindividuals,ortransgenderwomen(TW),areathighriskforHIVinfectionandfacemultiplebarrierstoHIVcare.AdvocatesagreethatnumerousfactorsneedtobeaddressedconcurrentlytopreventHIVinfectioninTW,includingprimaryhealthcare.Thisarticleexamineshowacommunity-basedclinicthatoffersfreeorlow-costcareaddressesthehealthcareneedsofTW.Atotalof20TWwhoattendedahealthcareclinicdedicatedtocommunity-basedhealthwereinterviewedregardingbestpracticesforHIVpreventionandprimarycare.In-depthinterviewswereconducted,transcribed,coded,andanalyzed.FactorsreportedtobeeffectiveforHIVpreventionandprimarycareincluded(a)accesstohealthcareinsettingsnotdedicatedtoservingtransgenderand/orgaycommunities,(b)afriendlyatmosphereandstaffsensitivity,and(c)holisticcareincludinghormonetherapy.Community-basedhealthcaresettingscanbeideallocalesforHIVpreventionandprimarycareforTW.
Keywords
∙community-basedhealthcare;
∙HIV;
∙HIVprevention;
∙male-to-femaletransgenderpersons;
∙primarycare
Thetermtransgenderreferstoadiversegroupofpeopleincludingmale-to-femaleortransgenderwomen(TW),female-to-maleortransgendermen(TM),bi-gender(i.e.,personswhoidentifywithbothmaleandfemalecharacteristics),andindividualswhomayormaynotcross-dress,undergosexreassignmentsurgeries,and/oraccesshormonetherapy([Bocktingetal.,1999a],[Bocktingetal.,1999b],[Clements-Nolleetal.,2001]and[Kenagy,2005]).Thegenderidentityoftransgenderindividualsdoesnotcorrespondorconformtothegenderassignedtothematbirth(Sausa,2003).Forexample,someoneassignedmalegenderatbirthmaychoosetousethetermwomantoidentifyherselformayusethetermtranssexual;inbothcases,thisindividualwouldbeclassifiedastransgender.Thetermtransgenderwomenisusedinthisreportforreasonsofclarityandalsoasareflectionofmanystudyparticipants'self-identificationaswomen.
HIVinfectionhasbeenreportedbyseveralresearcherstobehighamongTW([Clements-Nolleetal.,2001],[Kelloggetal.,2001],[Kenagy,2002],[Nemotoetal.,1999]and[Nemotoetal.,2004]a;[RisserandShelton,2002]and[Simon,2000]).Ametaanalysisof29studiesthatreportedHIVratesforTWshowedthatself-reportofHIVinfectionwas11.8%(Herbstetal.,2008).InametaanalysisofstudiesthatreportedHIVincidencethroughlaboratorytesting,27.7%ofTWparticipantswerereportedtobeinfectedwithHIV(Herbstetal.,2008).Additionally,researchershavenotedadecreaseduseofhighlyactiveantiretroviraltherapyamongHIV-infectedTW(Melendezetal.,2006).EvidencehassuggestedthatTWofcolorareatincreasedriskforHIVinfection([Clements-Nolleetal.,2001],[Nemotoetal.,1999]and[Sausa,2004]).Herbstetal.(2008)showedthatracialandethnicdisparitieswerepresentamongTW;half(56.3%)ofallAfricanAmericanTWwhoweretestedforHIVwereinfected,andHispanicTWhadanHIVinfectionrateof16.1%.
MultifactorConcernsofTransgenderWomen
Researchontransgenderindividualshasprimarilyfocusedonselectissuessurroundingtransgenderhealthcaresuchasgenderreassignmentprocedures([Abraham,1998]and[Beckeretal.,1998]),mentalhealth([Barber,2003],[JonesandHill,2003],[May,2002],[Medeirosetal.,2004]and[Nuttbrocketal.,2002]),andHIVriskandinfection([Bocktingetal.,1998a],[Bocktingetal.,1998b],[Bocktingetal.,1999a],[Clementsetal.,1999],[Kenagy,2002],[KenagyandHsieh,2005],[Namaste,1999]and[Nemotoetal.,1999];Nemoto,Operario,Keatley,Hanetal.,2004;Nemoto,Operario,Keatley,Oggins,&Villegas,2004).TheconcernsfacedbyTWrendertheexaminationofisolatedhealthissuesinadequateandineffectiveinimprovingtheoverallhealthofTW.GiventhemultiplehealthissuesthatimpactTW,anecologicalapproachtohealthcaremaybestreflecttheirneeds—anapproachthatsimultaneouslyaddressesmultipleissuesatmultiplelevels.
ResearchershaveexploredmyriadfactorsthatleadtoincreasedHIVrates(Herbstetal.2008).MentalhealthisanimportantareatoconsiderinHIVprevention.Onestudyreportedthat38%ofTWinWashington,DChadsuicidalthoughts(Xavier,Robbin,Singer,&Budd,2005).ViolenceisalsoamajorhealthconcernamongtransgenderindividualsandhasbeenreportedtobecloselylinkedtomentalhealthandHIVrisk(Clements-Nolleetal.,2001).InastudyofTWinSanFrancisco,59%oftheparticipants(n=392)experiencedforcedsexorrape(Clements-Nolleetal.,2001).ResearchhasalsoshownthatsubstanceabuseisaproblemofsignificantmagnitudeamongTWandisstronglyassociatedwithhighrisksexualbehaviors([Bocktingetal.,1998a]and[Clements-Nolleetal.,2001]).
AccesstoComprehensiveCare
StudieshavebeenconsistentinreportingbothhighratesofHIVandtheneedforhealthcareservicesforTWonanumberoffronts.BecauseoftheeconomichardshipsfacedbyTW([AsthanaandOostvogels,1993]and[Bocktingetal.,1998a];NationalCoalitionforLGBT[lesbian,gay,bisexual,&transgender]Health,2004),community-basedhealthclinicsthatofferfreeorlow-costhealthcaremaybeideallocationsforthehealthcareofTW.However,community-basedclinicsfaceanumberofchallengesinthecareofTWclients.
ComprehensiveHIVpreventioneffortsrequirenotonlyprimarycarebutalsoconsiderationofanumberofhealth-relatedissuesthataffectTW.HealthcareadvocatesarguethatonlyacomprehensiveapproachtoTWneedscanbegintocurbthehighratesofHIVinfectioninthispopulation.However,thetaskofprovidingHIVpreventionservicesandprimarycareisnoteasy.HealthcareclinicsmustaddressanumberoffactorsinadditiontoHIVtocurbthespreadofHIVinfection;theseincludethefollowing:
1.
Accesstocareincludinglow-costorfreecarefortransgenderindividualswhomaynotbeabletoaffordhealthcare,aswellasaccesstohormonesandothergenderreassignmentprocedures(NationalCoalitionforLGBTHealth,2004).
2.
Caresuitedfortransgenderindividualsinclu-dinghealthcareinlocationsthatarewelcomingandsafefortransgenderindividualsandthatofferinformationthatispertinenttotransgenderissues,aswellastheprovisionofcarewithoutthestigmaattachedtogenderidentitydisorder([AmericanPsychiatricAssociation,2000]and[NationalCoalitionforLGBTHealth,2004]).Theseadaptationsmayincludehiringtransgenderindividualsashealthcareworkers.
3.
Treatmentofmentalhealthissues,includingallpsychosocialconcernssuchasgenderidentitydisorderaswellasviolenceandabuse(NationalCoalitionforLGBTHealth,2004).
4.
Substanceabusetreatment,includingtreatmentforbothdrugsandalcohol.
5.
Culturallyspecifichealthcarewithrecognitionthattransgenderindividualscomefromavarietyofethnicandculturalbackgrounds.Transgenderpersonsmayrequireservicesinvariouslanguages(Deanetal.,2000).
Addressingtheseissuessimultaneouslyischallenging,especiallyintheUnitedStates,wherehealthcarecoverageismarkedbydisparities.Community-basedclinicsthatofferfreeorlow-costhealthcareprovideanalternativeforindividualswhoarewithoutthefinancialresourcestoreceivemedicalcare.Unfortunately,manyclinicsstrugglefortheresourcesnecessarytoprovideservicestoclients.Toadequatelyaddresssuggestedrecommendations,providersmustbefamiliarwiththepsychologicalandsocialissuessurroundingtransgenderidentitiesaswellashowtheseissuesaffecthealthcare.
Racialandethnichealthdisparitiesfurthercompoundissuesofgenderidentity.Forexample,Latinotransgenderindividualsmayfacebarriersrelatedtolanguageor,forindividualswhohaveundocumentedimmigrationstatus,fearthataccessingcaremayplacethematriskfordeportation(CentersforDiseaseControlandPrevention,2004).Providingcarethatisculturallycongruentfortransgenderindividualsisacostlyandtime-consumingtaskthatrequiresresourcesandthetrainingofserviceproviders.
Althoughmanyhealthcareclinicsthatservetransgendercommunitiesmaybeawareoftheneedsoftransgenderindividuals,itisunknownhowclinicsthatdonotspecializeintransgendercareaddressthehealthcareneedsofTW.AnumberofhealthclinicsserveLGBTindividuals([Garza,2004],[Hellman,2004],[Mayeretal.,2001]and[Medeirosetal.,2004]).WhereasprovidinghealthservicesinclinicsdevotedtoLGBTclientsisagoodresponsetosomeofthebarriersthattransgenderindividualshavefacedovertime,theremaybeadditionaldifficultiesintheprovisionofhealthservicestotransgenderindividualsinLGBTlocales.First,LGBThealthclinicsarenotsituatedinallgeographiclocations.Second,manyTWmaynotbecomfortablerevealinggenderidentityandmayprefertoidentifyaswomenratherthanastransgender.Third,eveniftheyarecomfortablerevealinggenderidentity,manyTWmayprefertoreceivecareinnon-LGBTfocusedclinics.Forexample,sometransgenderindividualsofcolormayfeeluncomfortableorunwelcomeinLGBTclinicsthatareperceivedaspredominantlyWhite([Garof
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