{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T02:30:26Z","timestamp":1787020226426,"version":"build-2736575974"},"reference-count":41,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2020,5,26]],"date-time":"2020-05-26T00:00:00Z","timestamp":1590451200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2020,5,26]],"date-time":"2020-05-26T00:00:00Z","timestamp":1590451200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"crossref","award":["R34MH115775"],"award-info":[{"award-number":["R34MH115775"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"crossref","award":["K01MH107310"],"award-info":[{"award-number":["K01MH107310"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Public Health"],"published-print":{"date-parts":[[2020,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Transgender women (\u201ctrans women\u201d), particularly African-American and Latina trans women, have disproportionately high prevalence of HIV in the United States (U.S.). In order to decrease gender dysphoria and overcome discrimination, trans women affirm their gender through social and medical transition, often in contexts of economic hardship and sexual risk. This study qualitatively examined how gender-affirming behaviors enhance or diminish vulnerability to HIV in light of structural and economic barriers to gender transition.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted individual interviews with 19 adult trans women in two U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment\/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The majority (74%) of trans women were racial\/ethnic minorities with mean age of 26.3\u2009years. Gender-affirming behaviors varied with 58% of trans women having legally changed their name and gender marker; 79% having initiated hormone therapy; and 11% having not initiated any medical or legal changes. None had undertaken surgical changes. Findings suggested that the process of gender transitioning resulted in both increasing and decreasing HIV risk. The high need for gender affirmation by male sex partners contributed to trans women\u2019s exposure to sexual objectification, sexual risk behaviors, and conflicting interests in HIV prevention messaging. Loss of housing and employment due to transition along with the high costs of transition products and medical visits increased reliance on sex work and created new obstacles in accessing HIV services. Trans women experienced lower HIV risk as they acquired legal and medical transition services, reshaped interactions with sex partners, and received gender-affirming support by others, including health providers, employers, peers, and housing professionals. Sexual abstinence was viewed as a negative consequence of incomplete transition, although characterized as a period of low HIV risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Structural and policy initiatives that promote safe gender transition and economic stability in trans women may play a critical role in reducing HIV in this population. Addressing the harmful pressures for U.S. trans women to conform to perceived feminine stereotypes may also serve an important role.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12889-020-08902-3","type":"journal-article","created":{"date-parts":[[2020,5,26]],"date-time":"2020-05-26T03:03:29Z","timestamp":1590462209000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":28,"title":["Combined effects of gender affirmation and economic hardship on vulnerability to HIV: a qualitative analysis among U.S. adult transgender women"],"prefix":"10.1186","volume":"20","author":[{"given":"Larissa","family":"Jennings Mayo-Wilson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric G.","family":"Benotsch","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheila R.","family":"Grigsby","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Wagner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatmata","family":"Timbo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tonia","family":"Poteat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lauretta","family":"Cathers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashlee N.","family":"Sawyer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shelby A.","family":"Smout","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rick S.","family":"Zimmerman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2020,5,26]]},"reference":[{"issue":"4","key":"8902_CR1","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1071\/SH19011","volume":"16","author":"Ashley Lacombe-Duncan","year":"2019","unstructured":"Lacombe-Duncan A, Newman PA, Bauer GR, Logie CH, Persad Y, Shokoohi M, O'Brien N, Kaida A, de Pokomandy A, Loutfy M. Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: a mixed-methods study. Sex Health 2019. doi: 10.1071\/SH19011.","journal-title":"Sexual Health"},{"key":"8902_CR2","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1016\/j.socscimed.2016.07.038","volume":"165","author":"AR Gordon","year":"2016","unstructured":"Gordon AR, Austin SB, Krieger N, White Hughto JM, Reisner SL. \"I have to constantly prove to myself, to people, that I fit the bill\": perspectives on weight and shape control behaviors among low-income, ethnically diverse young transgender women. Soc Sci Med. 2016 Sep;165:141\u20139.","journal-title":"Soc Sci Med"},{"issue":"12","key":"8902_CR3","doi-asserted-by":"publisher","first-page":"e018121","DOI":"10.1136\/bmjopen-2017-018121","volume":"7","author":"VP Quinn","year":"2017","unstructured":"Quinn VP, Nash R, Hunkeler E, Contreras R, Cromwell L, Becerra-Culqui TA, Getahun D, Giammattei S, Lash TL, Millman A, Robinson B, Roblin D, Silverberg MJ, Slovis J, Tangpricha V, Tolsma D, Valentine C, Ward K, Winter S, Goodman M. Cohort profile: study of transition, outcomes and gender (STRONG) to assess health status of transgender people. BMJ Open. 2017;7(12):e018121.","journal-title":"BMJ Open"},{"issue":"4","key":"8902_CR4","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1007\/s10508-017-1143-x","volume":"47","author":"Kirsty Clark","year":"2018","unstructured":"Clark K, Fletcher JB, Holloway IW, Reback CJ. Structural inequities and social networks impact hormone use and misuse among transgender women in Los Angeles County. Arch Sex Behav 2018;47(4):953\u2013962. doi: 10.1007\/s10508-017-1143-x. Epub 2018 Jan 8.","journal-title":"Archives of Sexual Behavior"},{"issue":"1","key":"8902_CR5","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1089\/trgh.2018.0005","volume":"3","author":"Rusi Jaspal","year":"2018","unstructured":"Jaspal R, Kennedy L, Tariq S. Human immunodeficiency virus and trans women: a literature review. Transgender Health 2018; Vol. 3.1:239\u2013250. doi: 10.1089\/trgh.2018.0005.","journal-title":"Transgender Health"},{"issue":"1","key":"8902_CR6","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1007\/s10461-019-02575-9","volume":"24","author":"Daniel Teixeira da Silva","year":"2019","unstructured":"Teixeira da Silva D, Bouris A, Voisin D, Hotton A, Brewer R, Schneider J. Social Networks Moderate the Syndemic Effect of Psychosocial and Structural Factors on HIV Risk Among Young Black Transgender Women and Men who have Sex with Men. AIDS Behav. 2019. doi: 10.1007\/s10461-019-02575-9.","journal-title":"AIDS and Behavior"},{"key":"8902_CR7","unstructured":"James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. Washington, DC: National Center for transgender equality. Accessed 28 august 2019 from URL: https:\/\/www.transequality.org\/sites\/default\/files\/docs\/USTS-Full-Report-FINAL.PDF."},{"issue":"1","key":"8902_CR8","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.2105\/AJPH.2018.304727","volume":"109","author":"Jeffrey S. Becasen","year":"2019","unstructured":"Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006-2017. Am J Public Health 2018 29:e1-e8. doi: 10.2105\/AJPH.2018.304727.","journal-title":"American Journal of Public Health"},{"issue":"1","key":"8902_CR9","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1007\/s13178-017-0289-6","volume":"15","author":"Brandon J. Hill","year":"2017","unstructured":"Hill BJ, Crosby R, Bouris A, Brown R, Bak T, Rosentel K, VandeVusse A, Silverman M, Salazar L. Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color. Sex Res Social Policy 2018;15(1):25\u201333. doi: 10.1007\/s13178-017-0289-6.","journal-title":"Sexuality Research and Social Policy"},{"issue":"1","key":"8902_CR10","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1089\/trgh.2018.0026","volume":"4","author":"John Frank","year":"2019","unstructured":"Frank J, Restar A, Kuhns L, Reisner S, Biello K, Garofalo R, Mimiaga MJ. Unmet Health care needs among young transgender women at risk for HIV transmission and Acquisition in two Urban U.S. cities: the LifeSkills study. Transgend Health. 2019;4(1):1\u20138. doi: 10.1089\/trgh.2018.0026. eCollection 2019.","journal-title":"Transgender Health"},{"key":"8902_CR11","doi-asserted-by":"crossref","unstructured":"Kuhns LM, Hotton AL, Perloff J, Paul J, Parker C, Muldoon AL, Johnson AK, Garofalo R. Evaluation of Translife care: an intervention to address social determinants of engagement in HIV care among transgender women of color. AIDS Behav 2019. doi: 10.1007\/s10461-019-02548-y.","DOI":"10.1007\/s10461-019-02548-y"},{"issue":"10","key":"8902_CR12","doi-asserted-by":"publisher","first-page":"2212","DOI":"10.1007\/s10461-016-1424-8","volume":"20","author":"Jerris L. Raiford","year":"2016","unstructured":"Raiford JL, Hall GJ, Taylor RD, Bimbi DS, Parsons JT. The role of structural barriers in risky sexual behavior, victimization and readiness to change HIV\/STI-related risk behavior among transgender women. AIDS Behav 2016;20(10):2212\u20132221. doi: 10.1007\/s10461-016-1424-8.","journal-title":"AIDS and Behavior"},{"issue":"8","key":"8902_CR13","doi-asserted-by":"publisher","first-page":"1651","DOI":"10.1007\/s10508-014-0368-1","volume":"43","author":"Jesse B. Fletcher","year":"2014","unstructured":"Fletcher JB, Kisler KA, Reback CJ. Housing status and HIV risk behaviors among transgender women in Los Angeles. Arch Sex Behav 2014;43(8):1651\u20131661. doi: 10.1007\/s10508-014-0368-1.","journal-title":"Archives of Sexual Behavior"},{"key":"8902_CR14","doi-asserted-by":"publisher","first-page":"386","DOI":"10.1353\/hpu.2016.0092","volume":"27","author":"MB Deutsch","year":"2016","unstructured":"Deutsch MB. Gender-affirming surgeries in the era of insurance coverage: developing a framework for psychosocial support and care navigation in the perioperative period. J Health Care Poor Underserved. 2016;27:386\u201391.","journal-title":"J Health Care Poor Underserved"},{"issue":"2","key":"8902_CR15","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1111\/j.1521-0391.2009.00022.x","volume":"19","author":"Donald A. Calsyn","year":"2010","unstructured":"Calsyn DA, Cousins SJ, Hatch-Maillette MA, Forcehimes A, Mandler R, Doyle SR, Woody G. Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior. Am J Addict 2010;19(2):119\u2013127. doi: 10.1111\/j.1521-0391.2009.00022.x.","journal-title":"The American Journal on Addictions"},{"key":"8902_CR16","doi-asserted-by":"publisher","first-page":"1049","DOI":"10.3109\/10826084.2013.855787","volume":"49","author":"BR Hoffman","year":"2014","unstructured":"Hoffman BR. The interaction of drug use, sex work and HIV among transgender women. Subs Use Misuse. 2014;49:1049\u201353.","journal-title":"Subs Use Misuse"},{"issue":"4","key":"8902_CR17","doi-asserted-by":"publisher","first-page":"e0194306","DOI":"10.1371\/journal.pone.0194306","volume":"13","author":"L Magno","year":"2018","unstructured":"Magno L, Dourado I, Silva LAVD, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One. 2018;13(4):e0194306.","journal-title":"PLoS One"},{"issue":"6","key":"8902_CR18","doi-asserted-by":"publisher","first-page":"e0219169","DOI":"10.1371\/journal.pone.0219169","volume":"14","author":"P Seekaew","year":"2019","unstructured":"Seekaew P, Lujintanon S, Pongtriang P, Nonnoi S, Hongchookait P, Tongmuang S, Srisutat Y, Phanuphak P, Phanuphak N. Sexual patterns and practices among men who have sex with men and transgender women in Thailand: a qualitative assessment. PLoS One. 2019;14(6):e0219169.","journal-title":"PLoS One"},{"issue":"7","key":"8902_CR19","doi-asserted-by":"publisher","first-page":"870","DOI":"10.1080\/09540121.2017.1286288","volume":"29","author":"T Anand","year":"2017","unstructured":"Anand T, Nitpolprasert C, Kerr SJ, Muessig KE, Promthong S, Chomchey N, Hightow-Weidman LB, Chaiyahong P, Phanuphak P, Ananworanich J, Phanuphak N. A qualitative study of Thai HIV-positive young men who have sex with men and transgender women demonstrates the need for eHealth interventions to optimize the HIV care continuum. AIDS Care. 2017;29(7):870\u20135.","journal-title":"AIDS Care"},{"issue":"1","key":"8902_CR20","doi-asserted-by":"publisher","first-page":"21796","DOI":"10.7448\/IAS.20.01.21796","volume":"20","author":"AL Wirtz","year":"2017","unstructured":"Wirtz AL, Clouse E, Veronese V, Thu KH, Naing S, Baral SD, Beyrer C. New HIV testing technologies in the context of a concentrated epidemic and evolving HIV prevention: qualitative research on HIV self-testing among men who have sex with men and transgender women in Yangon. Myanmar J Int AIDS Soc. 2017;20(1):21796.","journal-title":"Myanmar J Int AIDS Soc"},{"issue":"11","key":"8902_CR21","doi-asserted-by":"publisher","first-page":"e0166129","DOI":"10.1371\/journal.pone.0166129","volume":"11","author":"K Pal","year":"2016","unstructured":"Pal K, Ngin C, Tuot S, Chhoun P, Ly C, Chhim S, Luong MA, Tatomir B, Yi S. Acceptability study on HIV self-testing among transgender women, men who have sex with men, and female entertainment Workers in Cambodia: a qualitative analysis. PLoS One. 2016;11(11):e0166129.","journal-title":"PLoS One"},{"issue":"1","key":"8902_CR22","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1186\/s12914-019-0187-5","volume":"19","author":"E Evens","year":"2019","unstructured":"Evens E, Lanham M, Santi K, Cooke J, Ridgeway K, Morales G, Parker C, Brennan C, de Bruin M, Desrosiers PC, Diaz X, Drago M, McLean R, Mendizabal M, Davis D, Hershow RB, Dayton R. Experiences of gender-based violence among female sex workers, men who have sex with men, and transgender women in Latin America and the Caribbean: a qualitative study to inform HIV programming. BMC Int Health Hum Rights. 2019;19(1):9.","journal-title":"BMC Int Health Hum Rights"},{"key":"8902_CR23","first-page":"886260518787811","volume":"26","author":"E Ju\u00e1rez-Ch\u00e1vez","year":"2018","unstructured":"Ju\u00e1rez-Ch\u00e1vez E, Cooney EE, Hidalgo A, S\u00e1nchez J, Poteat T. Violence experiences in childhood and adolescence among gay men and transgender women living in Per\u00fa: a qualitative exploration. J Interpers Violence. 2018;26:886260518787811.","journal-title":"J Interpers Violence"},{"issue":"7","key":"8902_CR24","doi-asserted-by":"publisher","first-page":"831","DOI":"10.1080\/10826084.2016.1264968","volume":"52","author":"P Vagenas","year":"2017","unstructured":"Vagenas P, Brown SE, Clark JL, Konda KA, Lama JR, S\u00e1nchez J, Duerr AC, Altice FL. A qualitative assessment of alcohol consumption and sexual risk behaviors among men who have sex with men and transgender women in Peru. Subst Use Misuse. 2017;52(7):831\u20139.","journal-title":"Subst Use Misuse"},{"issue":"2","key":"8902_CR25","doi-asserted-by":"publisher","first-page":"e0172964","DOI":"10.1371\/journal.pone.0172964","volume":"12","author":"JT Galea","year":"2017","unstructured":"Galea JT, Monsour E, Nure\u00f1a CR, Blas MM, Brown B. HPV vaccine knowledge and acceptability among Peruvian men who have sex with men and transgender women: a pilot, qualitative study. PLoS One. 2017;12(2):e0172964.","journal-title":"PLoS One"},{"issue":"11\u201312","key":"8902_CR26","doi-asserted-by":"publisher","first-page":"675","DOI":"10.1007\/s11199-012-0216-5","volume":"68","author":"JM Sevelius","year":"2013","unstructured":"Sevelius JM. Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11\u201312):675\u201389.","journal-title":"Sex Roles"},{"issue":"1","key":"8902_CR27","first-page":"43","volume":"44","author":"RA Crosby","year":"2007","unstructured":"Crosby RA, Pitts NL. Caught between different worlds: how transgendered women may be \"forced\" into risky sex. J Sex Res. 2007;44(1):43\u20138.","journal-title":"J Sex Res"},{"key":"8902_CR28","unstructured":"Nadal KL, Vargas VH, Meterko V, Hamit S, Mclean K. Chapter 6: \u201cTransgender female sex workers in New York City: personal perspectives, gender identity development, and psychological processes.\u201d 2012. Pgs. 123\u2013153 in Managing Diversity in Today's Workplace: Strategies for Employees and Employers, Volume 1: Gender, Race, Sexual Orientation, Ethnicity, and Power. Editor: Paludi, MA. Santa Barbara, CA: Praeger. 2012 by ABC Clio."},{"issue":"1","key":"8902_CR29","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1089\/trgh.2016.0046","volume":"2","author":"Nadia Dowshen","year":"2017","unstructured":"Dowshen N, Lee S, Franklin J, Castillo M, Barg F. Access to medical and mental health services across the HIV care continuum among young transgender women: a qualitative study. Transgend Health 2017;2(1):81\u201390. doi: 10.1089\/trgh.2016.0046. eCollection 2017.","journal-title":"Transgender Health"},{"key":"8902_CR30","unstructured":"Center for Disease Control and Prevention. HIV Surveillance Report, 2017; Vol. 29. URL accessed on 21 September 2019. https:\/\/www.cdc.gov\/hiv\/pdf\/library\/reports\/surveillance\/cdc-hiv-surveillance-report-2017-vol-29.pdf."},{"key":"8902_CR31","unstructured":"Missouri Department of Health and Senior Services. Data & Statistical Reports. Epidemiologic Profiles of HIV\/AIDS and STDs in Missouri. 2017 Epidemiologic profile: St. Louis HIV region. URL accessed 21 September 2019: https:\/\/health.mo.gov\/data\/hivstdaids\/data.php."},{"key":"8902_CR32","unstructured":"Virginia Department of Health. Virginia HIV Epidemiologic Profile. 2016. Pages 1\u201360. URL accessed 21 September 2019: http:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/10\/2017\/02\/HIV_Epi_Profile_2016.pdf."},{"key":"8902_CR33","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1080\/21642850.2015.1093423","volume":"3","author":"RS Zimmerman","year":"2015","unstructured":"Zimmerman RS, Benotsch EG, Shoemaker S, Snipes DJ, Cathers L, Perrin PB, McMillan D, Pierce J, McNulty S, Heck T. Mediational models linking psychosocial context, mental health problems, substance use and HIV risk behaviors in transgender women. Health Psychology and Behavioral Medicine. 2015;3:379\u201390.","journal-title":"Health Psychology and Behavioral Medicine"},{"key":"8902_CR34","doi-asserted-by":"publisher","first-page":"776","DOI":"10.1177\/0956462415595319","volume":"27","author":"EG Benotsch","year":"2016","unstructured":"Benotsch EG, Zimmerman RS, Cathers L, Pierce J, McNulty S, Heck T, Perrin PB, Snipes DJ. Non-medical use of prescription drugs and HIV risk behaviour in transgender women in the mid-Atlantic region of the United States. Int J STD AIDS. 2016;27:776\u201382.","journal-title":"Int J STD AIDS"},{"key":"8902_CR35","unstructured":"Transgender Health: Building Local Trans Communities. Vol. 4. Issue 3. Winter 2010. Richmond, Virginia. Pages 1\u20138. URL accessed on 21 September 2019: http:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/10\/2016\/12\/TransNewsV4_Issue3.pdf."},{"key":"8902_CR36","unstructured":"Patton. Qualitative evaluation and research methods. Sampling Sage Publications Pages. 1990:169\u201386."},{"issue":"13","key":"8902_CR37","doi-asserted-by":"publisher","first-page":"1753","DOI":"10.1177\/1049732315617444","volume":"26","author":"Kirsti Malterud","year":"2016","unstructured":"Malterud. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual. Health Res. 2015:1753\u201360.","journal-title":"Qualitative Health Research"},{"key":"8902_CR38","doi-asserted-by":"crossref","unstructured":"Mays. Qualitative research in health care: assessing quality in qualitative research. BMJ. 2000;(320):50\u20132.","DOI":"10.1136\/bmj.320.7226.50"},{"key":"8902_CR39","doi-asserted-by":"publisher","first-page":"1277","DOI":"10.1177\/1049732305276687","volume":"15","author":"H-F Hsieh","year":"2005","unstructured":"Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277\u201388.","journal-title":"Qual Health Res"},{"key":"8902_CR40","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1177\/1098214005283748","volume":"27","author":"DR Thomas","year":"2006","unstructured":"Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am J Eval. 2006;27:237\u201346.","journal-title":"Am J Eval"},{"issue":"12","key":"8902_CR41","doi-asserted-by":"publisher","first-page":"3328","DOI":"10.1007\/s10461-016-1509-4","volume":"21","author":"LA Nuttbrock","year":"2017","unstructured":"Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV\/STI among transgender women in New York City: a three year prospective study. AIDS Behav. 2017;21(12):3328\u201335.","journal-title":"AIDS Behav"}],"container-title":["BMC Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12889-020-08902-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12889-020-08902-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12889-020-08902-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,5,25]],"date-time":"2021-05-25T19:09:52Z","timestamp":1621969792000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpublichealth.biomedcentral.com\/articles\/10.1186\/s12889-020-08902-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,5,26]]},"references-count":41,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2020,12]]}},"alternative-id":["8902"],"URL":"https:\/\/doi.org\/10.1186\/s12889-020-08902-3","relation":{},"ISSN":["1471-2458"],"issn-type":[{"value":"1471-2458","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,5,26]]},"assertion":[{"value":"8 October 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 May 2020","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 May 2020","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study obtained ethical approval from the Virginia Commonwealth University (VCU) Office of Research and Innovation Institutional Review Board (IRB) (#HM20011245) and the University of Missouri \u2013 St. Louis (UMSLM) IRB (#1179371\u20132). Oral informed consent to participate was approved by both IRBs as the signature requirement would have been the only record linking the subject and the research, and a possible risk would have been potential harm resulting from a breach of confidentiality. Oral informed consent was obtained from all trans women prior to the start of data collection.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"782"}}